para>Focal lesions extending progressively in all directions
Lesions adherent (fixed) to the deep chest wall fascia
Lesions extending to the skin and producing retraction and dimpling
Lymphatic blockage producing skin thickening, lymphedema, and peau d 'orange (orange peel) changes
Main ductal involvement producing nipple retraction
Widespread infiltration of the breast producing acute redness, swelling, and tenderness (i.e., inflammatory carcinoma)
Adapted from Cotran RS, Kumar V, Robbins SL, et al. Robbins Pathologic Basis of Disease. Philadelphia: WB Saunders, 1994:1089 " ô1111.
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TABLE 77-3. Breast Needle Aspiration Cytology of Solid Lesions and Recommended Follow-up View Large TABLE 77-3. Breast Needle Aspiration Cytology of Solid Lesions and Recommended Follow-up Result Suggested Follow-up Scant or insufficient cells for diagnosis Repeat needle aspiration or biopsy if clinical suspicion is high, or use guided biopsy Benign " öfibroadenoma Reassurance or symptomatic treatment if cellular changes are not complex or associated with atypical hyperplasia Benign " öfibrocystic Symptomatic treatment if not associated with atypical hyperplasia Benign " öother (includes fat necrosis, lipoma, inflammation, papilloma, and other benign ductal epithelium) Reassurance and clinical follow-up Atypical cells Clinical follow-up can be considered reactive or degenerative atypia (seen in fibrocystic change); mammogram and biopsy for most atypia (especially if severe atypia) Suspicious for malignancy Surgical referral and biopsy Malignant cells Surgical referral and biopsy
Equipment
Please see the follow appendixes for supply information: é á
- Appendix A: Informed Consent
- Appendix C: Bacterial Endocarditis Prevention Recommendations
- Appendix E: Skin Preparation Recommendations
- Appendix I: Suggested Tray for Soft Tissue Aspiration and Injection Procedures
- Two sterile plain evacuated blood tubes
- Needles, 21, 22, 23 gauge
- Syringe of appropriate size
- Pistol grip device if desired
- Slides with frosted ends (three or four)
- Glass cover slips or extra slides for smearing the specimens
- Gauze pads, 4 â Ś 4 inches
- Sterile gloves
- Alcohol, povidone-iodine, or chlorhexidine swabs
- Syringe (1 mL) with 30-gauge needle and 1% " élidocaine for anesthesia
Indications
- Presence of a palpable mass in the breast
Contraindications
- Local infection
- Absence of a qualified cytopathologist capable of interpretation of the FNA slides
- Lack of clinician training with the procedure
- Severely immunocompromised patients (relative contraindication)
The Procedure
Step 1
Several devices may be used for the FNA procedure. A 21-gauge butterfly with extension tubing can be attached to any device or syringe and used with a nurse applying the back pressure and the clinician focusing full attention on the needle tip. The mechanical movement for the Cameco pistol syringe (shown) is produced by motion of the arm and elbow. This device allows for easy application of extensive suction and good control of the syringe and needle. é á
Step 1 View Original Step 1 View Original
Step 2
Palpate the lesion, and mark the skin to indicate the point of needle entry. Prep the skin with alcohol, povidone-iodine, or chlorhexidine solution (see Appendix E). Attach the needle, and draw approximately 1 mL of air into the syringe. é á
Step 3
Use the nondominant hand to surround and stabilize the lesion. Surrounding the lesion allows the sensory portion of the fourth and fifth fingers to feel the needle tip enter the lesion as the lesion moves against these fingers. Rarely, the glove may need to be removed from the nondominant hand if it interferes with palpation of the lesion. Make sure the patient understands why the glove is being removed. é á
Step 4
Insert the needle into the lesion, and withdraw the plunger to create a vacuum. If the lesion is a cyst, the fluid will usually flow easily into the syringe. Withdraw all of the fluid and palpate the area to be sure the lesion is completely gone. If residual lesion is present, consider an open biopsy. If the cyst completely disappears and the fluid is not bloody, the fluid does not have to be sent for analysis. Otherwise, submit the fluid on slides or in a sterile (without anticoagulant) blood collection tube. é á
Step 4 View Original Step 4 View Original
Step 5
If the lesion is solid, make 10 to 20 up-and-down passes, keeping the needle in the lesion. The sample will fill the needle and possibly part of the hub. With the needle still in the lesion, return the plunger to the resting position to release the suction. Then withdraw the needle from the skin. é á
Step 6
With the needle pointed downward, use the air in the syringe to deposit the sample into monolayer preservative or onto the slide. é á
Step 6 View Original Step 6 View Original
Step 7
When using a slide, place a second glass slide upside down on top of the original slide, and then gently pull the slides in opposite directions to smear the cellular contents over both slides. This technique usually yields two to four slides. é á
Step 7 View Original Step 7 View Original
Step 8
Apply spray fixative as when obtaining a Papanicolaou smear. If a solid-core specimen is expressed from the needle (rare), wash it from the slide into a vial of preservative, and submit it for histologic examination. Remove the syringe from the needle, replace it with a fresh one, and repeat the procedure if desired. é á
Step 8 View Original Step 8 View Original
Step 9
Apply compression to the aspiration site with a gauze pad for 5 to 10 minutes to help minimize bruising. Place several folded gauze pads under a snug brassiere to form a compression dressing. é á
Step 9 View Original Step 9 View Original
Complications
- The major risk of the FNA procedure is failure to place the needle tip into the lesion. Significant complications of FNA, such as pneumothorax, are rare. Some patients experience mild soreness, hematoma formation, and skin discoloration. The patient with controlled anticoagulation may safely undergo FNA if parameters are in the therapeutic range and adequate site compression is used after the procedure to avoid hematoma. All patients undergoing FNA of breast lesions should wear a supportive brassiere after the procedure.
Pediatric Considerations
This procedure is usually not performed in the pediatric age groups. é á
Postprocedure Instructions
Instruct the patient to leave the pressure dressing in place for at least several hours to prevent hematoma formation. A small ice pack can be applied to the FNA site for 15 to 60 minutes after the procedure if desired. The samples are sent for cytologic or histologic analysis using staining and simple microscopy or a monolayer system. Arrange for a follow-up visit to discuss results. é á
Coding Information and Supply Sources
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View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 19000 Aspiration drainage of a breast cyst; one cyst $201.00 0 19001 Aspiration drainage of a breast cyst; each additional cyst $111.00 0 10021 FNA without imaging guidance $227.00 XXX XXX, global concept does not apply.CPT is a registered trademark of the American Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008 MMH-SI 's copyrighted Physicians ' Fees and Coding Guide.
Common ICD9 Codes
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View Large 174.0 Malignant neoplasm of female breast; nipple and areola 174.4 Malignant neoplasm of female breast; upper/outer quadrant 174.6 Malignant neoplasm of female breast; axillary tail 174.9 Malignant neoplasm of breast (female) unspecified 217 Benign neoplasm of breast: connective tissue, glandular tissue, soft parts. Excludes adenofibrosis, benign cyst of breast, fibrocystic disease, skin of breast 610.0 Solitary cyst of breast 610.1 Diffuse cystic mastopathy 610.2 Fibroadenosis of breast 611.0 Inflammatory disease of breast: abscess or mastitis (acute) (chronic) (nonpuerperal) of areola, breast, mamillary fistula
Suppliers
- The Cameco syringe pistol ($286) is available from Precision Dynamics Corporation, 13880 Del Sur Street, San Fernando, CA 91340-3490. Phone: 1-800-772-1122. Web site: http://www.pdcorp.com, although this item is not on their Web site.
- Morton Medical Ltd., 262a Fulham Road, London SW10 9EL. Phone, UK only: 0207 352 1297; phone outside of the UK: +44 207 352 1297. Web site: http://www.mortonhealthcare.co.uk/products_index.htm
Note that the FNA-21 fine-needle aspiration device from CooperSurgical has been discontinued. é á
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2008 MAG Mutual Healthcare Solutions, Inc. 's
Physicians ' Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.
2007.