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Cytopathologists and Ultrasound-Guided Fine-Needle Aspiration: Embracing the Black and White

Powers, Celeste N. MD, PhD; Kraft, Adele O. MD

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doi: 10.1097/PCR.0000000000000250
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Over the last several years, we have witnessed the rapid decline in pathologist-performed, palpation-guided fine-needle aspirations (FNAs). This is due in large measure to continuous improvements in ultrasound (US) instrumentation such that nonradiologists can also comfortably and successfully interpret and target superficial masses. Ultrasound with or without FNA is also often used to evaluate masses that are palpable. Practice patterns in this new paradigm vary tremendously from complete relegation of FNAs to radiologists to a hybrid or multidisciplinary FNA service that may include pathologist-performed US-guided FNAs (USFNA).

Diagnostic US teaching is being widely incorporated in undergraduate medical education curricula across the United States. With the advent of mobile device–based equipment, US has been dubbed “the new stethoscope.”1 With their knowledge of normal and abnormal anatomy, pathologists, once acquiring basic imaging interpretation skills, can easily correlate gross pathology with US images. Whether pathologists actively perform USFNA, the need to interpret US images and reports in the context of the aspiration biopsy is essential. Thyroid FNA is only 1 example of how US findings need to be taken into consideration for a meaningful diagnostic interpretation. Cytopathologists have only to gain by embracing the black and white.

In 2013, Pathology Case Reviews published an issue devoted to USFNA: Ultrasound-Guided Fine-Needle Aspiration Biopsy: The Cytopathologist's Next Frontier was the subject of its January issue.2 This issue was designed to introduce the concept of US as an adjunct to pathologist-performed FNA. At that time, with the exception of a few long-standing FNA practices that had rapidly embraced USFNA, pathologists were faced with a changing paradigm and a future that included USFNA. Since 2013, USFNA has become the norm. Indeed, in many pathology practices, palpation-guided FNAs are now only a small fraction of their FNA services. This has been coupled with an almost logarithmic increase in the number of “deep” aspirations that require rapid on site evaluation, which has shifted workflow and staffing. In many institutions, this increasing focus on radiological performed procedures combined with the lack of desire or support for a separate US service in pathology has resulted in diminishing palpation-guided FNAs.

Now, 5 years later, US has become integral in the performance and interpretation of most FNAs, especially FNAs in the head and neck region. Whether your practice involves pathologist-performed USFNAs or is the recipient of radiologist-, endocrinologist-, or surgeon-performed USFNAs, US is pervasive. This issue is designed to provide insights into the utility of US for those who perform USFNAs as well as an approach to understanding the usefulness of US images in the diagnosis of various entities. The majority of this issue focuses on head and neck lesions. Where the strategy for the 2013 issue was to demystify and encourage pathologists to embrace US as an enhancement to the already successful FNA technique, the goal of this issue is to build upon that foundation with pragmatic advice for those performing USFNA and to review diagnostic clues and pitfalls that US images can provide during the workup of mass lesions.

We begin with a brief exploration of how USFNA can be incorporated into a cytopathology practice. Four unique practice venues are compared and contrasted. All of our authors have years of experience and/or specific training in USFNA, and the subsequent articles have tapped their knowledge in both the USFNA technique and diagnosis using review and case presentation formats.

Those pathologists new to USFNA are often concerned that the only way to gain experience is through practice—typically on a patient! Nonpatient options are available and include the ever popular chicken breast with grapes and/or olives and the, often expensive, commercially available phantoms. Drs Jug and Jiang discuss another approach using gelatin to create a customized phantom. Our reviews focus on the 2 major organs of the head and neck, thyroid and salivary gland. Drs Jiang and Foo have a pragmatic approach to visualizing and targeting thyroid nodules, whereas Drs Wiles, Kraft, and Powers review the pros and cons of US in the other major organ in the head and neck, the salivary gland.

The subsequent case studies represent a variety of diagnostic challenges and/or problems that may be encountered in routine practice as well as a practical demonstration using breast lesions of how the triple test of history, imaging, and cytomorphology should be used to avoid false-positive and reduce false-negative results.

The last decade has seen the virtual elimination of breast aspirations in favor of needle core biopsies as the initial procedure in the workup of a patient with a breast mass. Very few institutions have palpation and USFNA as their first approach to sampling these masses. Dr Sanchez, as director of the Leslie Simon Breast Care and CytoDiagnosis Center, has maintained FNA as the primary technique in the algorithmic approach to evaluation of breast masses. Drs Sanchez, Burga, Tismenetsky, and Goldfischer present a case study of 2 patients that illustrates the need for sampling of breast lesions even when imaging appears “diagnostic.” The remaining studies are focused on the head and neck region. Drs Kraft and Prasad present an interesting and challenging thyroid case, whereas Drs Sayeed and Powers review the pros and cons of US when confronted with cystic salivary gland lesions. Finally, the head and neck region, in particular, has numerous lymph nodes that can show distinctive US patterns that help narrow the diagnostic differential; however, aspiration cytopathology is still essential. Drs Kraft and Wiles present an interesting lymph node aspiration that addresses one of the major differentials, infection, whereas Drs Jug and Jiang discuss one of the potentially frustrating technical problems: the deep lymph node.

It is our hope that this issue has provided those of you who are currently performing USFNA some helpful tips, and for those who are contemplating USFNA in your current practice, reassurance. Cytopathology continues to be a challenging but satisfying discipline that is constantly evolving. Understanding US and embracing USFNA are ways that we can continue to be at the forefront of patient-centered practice.


1. Dinh VA, Fu JY, Lu S, et al. Integration of ultrasound in medical education at United States medical schools: a national survey of directors' experiences. J Ultrasound Med 2016;35(2):413–419.
2. Powers CN, Jakowski JD. Ultrasound-guided fine-needle aspiration biopsy: the cytopathologist's next frontier. Pathol Case Rev 2013;18(1):1–63.
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