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Ultrasound-Guided Fine-Needle Aspiration Biopsy: The Cytopathologist’s Next Frontier

Powers, Celeste N. MD, PhD; Jakowski, Joseph D. MD

doi: 10.1097/PCR.0b013e318281c75d

From the Medical College of Virginia Hospitals, Virginia Commonwealth University Health System, Richmond VA.

Reprints: Celeste N. Powers, MD, PhD, Department of Pathology, Virginia Commonwealth University Health System, PO Box 980139, Richmond, VA 23298-0139. E-mail:

The authors have no funding or conflicts to declare.





“New capabilities emerge just by virtue of having smart people with access to state-of-the-art technology.” – Robert E. Kahn, American pioneer and codesigner of the networking protocols, which are the basis for the current Internet.

We have entered the 21st century with more than 50 years of guiding principles and techniques in fine-needle aspiration (FNA) biopsy, a procedure that has revolutionized the practice of cytopathology. Today, FNA is practiced worldwide and is accepted as a fast, safe, reliable, and accurate diagnostic procedure. Increasingly, however, clinicians are requesting ultrasound-guided FNA (USFNA) in lieu of palpation-guided FNA, even for superficial masses. Unfortunately at present, cytopathologists have little control over this shift; however, they must address its negative consequences. Obviously, a major issue is the decrease in palpation-guided FNAs performed by the cytopathologist resulting not only in declining revenues but also more importantly in diminishing expertise in FNA, which ultimately impacts the training of future cytopathologists. Second, there is a tremendous increase in the need for cytopathologists to provide rapid on-site assessments of USFNAs performed by other medical specialists, a time-consuming and inadequately compensated process. Third, the benefits of having the cytopathologist perform and interpret FNAs are the-well documented decrease in the unsatisfactory rate and increase in diagnostic accuracy when compared with noncytopathologist-performed FNA. Additional problems occur when the cytopathologist is not in control of the FNA procedure, including but not limited to improper sample triage, insufficient acquisition of material for ancillary studies, and diminished direct communication with patients and referring clinicians. To paraphrase Dr Miguel Sanchez, we should not allow cytopathology to merely become a form of “aesthetic morphology” but, instead, persist in its being recognized as a unique form of medical practice.

With these thoughts in mind, ultrasound (US) machines today are operator friendly and of reasonable cost and increased availability of training in the United States. With US, cytopathologists can expand their FNA capabilities to the real-time assessment of their patients’ lesions and USFNA of palpable and nonpalpable superficial lesions. This is analogous to the many nonradiologist physicians, including endocrinologists, intensivists, and surgeons, who have already realized the benefits of US for their focused patient evaluations and as an adjunct to their interventional procedures. To successfully incorporate this state-of-the-art technology into our profession, however, we must have a clear understanding of the goals and scope of practice, establish certification criteria and educational programs, and adhere to quality assurance. The goal and scope of US by the cytopathologist is for the evaluation and confirmation of a target for FNA and for the guidance of the needle during the USFNA procedure. Certification in USFNA has already been established for pathologists by the College of American Pathologists. Ultrasound-guided FNA education for cytopathologists is also increasing via peer-reviewed pathology publications, pathologist-directed courses, and through dedicated and experienced cytopathologists willing to provide hands-on training in USFNA. Ultrasonography quality assurance programs and accreditation specific to pathology do not currently exist because they do for many other medical specialties. However, there are applicable US practice standards already established by the American Institute of Ultrasound in Medicine and the American College of Radiology.

It is therefore with great enthusiasm that we devote this entire Pathology Case Reviews issue to cytopathologist-performed USFNA. The goal of this issue is to familiarize the reader with the fundamentals of USFNA and, as such, it is designed to be best appreciated when read in sequence. We are fortunate to have contributions from private and academic practices with longstanding experience in both the procedure and interpretation of USFNA. In addition to the insights and lessons learned from these experienced groups, we also have cytopathologists with newly initiated USFNA services who discuss their experiences. A minipractice description from each of the 5 institutions contributing to this issue begins your journey.

The mastery of a new field of study is predicated on the ability to comprehend its language and basic processes. Our first 2 reviews are designed by Dr Joe Jakowski to be an introduction for pathologists to the essentials of ultrasonography. The first article, “Basics of the Sonography and Ultrasound Terminology,” introduces the reader to the fundamentals of US terminology and how to obtain and interpret the sonographic image. This is followed by a brief primer on normal sonographic anatomy. The final piece in this triad is a visual essay on the performance of USFNA. You are now ready to test your skills with the several case studies.

In the Case Review section, all of our authors have contributed 2 cases from their USFNA practices that illustrate a mixture of routine diagnoses and unusual presentations. There are practical points that resonate throughout this issue, as well as specific “tricks of the trade” that can be gleaned from these cases. We have focused on breast and the head and neck region because this is currently the predominant case mix for most practices. Dr Abele’s cases capture the important concepts of thyroid USFNA. Drs Jakowski, Kraft, and Powers review the US findings of normal and abnormal lymph nodes and discuss their approach to USFNA of nonpalpable lesions. Drs Tambouret and Pitman present an unusual case involving a lymph node, whereas Dr Pitman’s second case with Dr Ly, as well as cases by Drs Tismenetsky and Sanchez discuss the issues and difficulties related to USFNA of the breast. Our final two cases round out our presentations with USFNA of a salivary gland and a soft tissue mass, both cases deftly discussed by Drs Khanafshar and Ljung.

The second part of this issue addresses the next important question of “how do you integrate USFNA into your practice setting?” Dr Abele and Drs Ljung and Pitman have developed USFNA practice guides based on their private practice and academic perspectives, respectively. They share their dos and don’ts, lessons learned (sometimes the hard way!), and savvy advice for those interested in initiating a USFNA practice. Finally, Drs Jakowski and Powers close with some additional pointers presented as a summary of results from a 15-question survey based on frequently asked questions regarding the practice of USFNA by cytopathologists.

In conclusion, we hope you enjoy this issue and that it helps many of you take the first steps toward becoming accomplished in USFNA! As Dr Abele would say, “Light it up!”

© 2013 Lippincott Williams & Wilkins, Inc.