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Rapid Responses: Rapid Responses published:
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FNAC is effective even in the hands of surgeons if done properly
- Diwa Nath Das (30 July 2004)
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Useful if you can get it
- John P Brush (3 August 2004)
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Most die with thyroid cancer, not from it. Over-investigation may cause harm
- Harry Rogers (19 March 2009)
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Diwa Nath Das, SAS L&I DGH,PA34 4HH
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FNAC is a very useful investigation to know the nature of a lump.Most of the failure is due to faulty technique and like any technique it needs periodical reinforcement. I am going to describe a few very critical steps for good cellular material for readers' benifit.They rarely failed me and even my grumpy consultant acknowledges that and refers to me all his cases. The most important thing to understand in FNAC is that it is the needle that gets the sample and the sample stays inside its hollow bore.I take a 10cc disposable syringe and size 21G needle.I keep slides and fixative ready with right side up.I pull the plunger at 3-4 ml mark at the beginning of procedure.This quantity of air inside the syringe helps in expelling the cellular material on to the slide at the end of procedure.Now the needle is introduced in to the lump and suction started while 7-10 stabs are made into different directions of the lump without withdrawing the needle out of lump.Now the most crucial step is that I release the plunger while still inside the lump and pull the syringe out of lump.This crucial step helps in preventing sucking of cellular sample into the lumen of syringe and keeps it inside the bore of needle.Then I make two slide with fixative and two air dried. I narrated the procedure in some detail to make it absolutelu clear that FNAC is getting bad publicity not because the procedure is unsatisfacory but because it is not done properly. Competing interests: None declared |
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John P Brush, Consultant Radiologist Western General Hospital, Edinburgh
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I agree that FNA is a safe,relatively easy procedure to perform without significant morbidity. It is particularly useful as a radiologist to have immediate "hot" access to this at the bedside to prevent unnecessary repeated passes. The ability of a cytopathologist to immediately inform that the first pass into a deep lung lesion, adjacent to the left main pulmonary artery has yielded a diagnosis, results in a safer procedure and a happier radiologist! However due to lack of staffing, I have only ever experienced the presence of a cytologist while working in another country ( Canada ) and a nearby district general hospital. I have never had the luxury of immediate cytological analysis in my place of work, a tertiary referral Oncology hospital! For this reason, I tend to perform core biopsies on everything but the most inaccessible lesions. These are usually 18G cores although I will use 20G biopsy devices for deeper lesions. I am aware that using co-axial devices and repeating biopsies lengthens this procedure significantly although I have not seen an unacceptable number of complications. I am also often reminded by local Pathologists that core biopsies allow greater certainty in the final diagnosis( in particular classification of lymphoma ) Perhaps in an ideal world fine needle aspiration with immediate cytology would represent the gold standard but at least in our hospital, further investment in Pathology is required to offer this service.Meanwhile I will continue my " not so fine " needle biopsy service as I find it offers the highest likelihood of making the diagnosis at the first procedural attempt. Competing interests: None declared |
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Harry Rogers, General Physician 3000
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I read with interest the review by Mehanna, but I am dismayed by its simplicity, and concerned about potential harm to patients. According to the review, 50-70% of patients have nodules on ultrasound. This is true. Conversely this means 30-50% do not have nodules. This means it is normal to have thyroid nodules (perhaps abnormal not to have them). Should we investigate 1 in 2 people? Elsewhere, it states 5% of nodules are malignant. Assuming the lower prevalence of 50%, this means 2.5% of the population have thyroid cancer. Clearly not true. So, in the era of high resolution ultrasound, the rate of thyroid malignancy, particularly when a incidental finding, is much lower. But, moreover, the significance of finding thyroid cancer remains uncertain. Most thyroid malignancies are papillary which are have a remarkably good prognosis. Many older patients die with their thyroid cancer, rather than from it, much akin to prostate cancer. Utilizing 2–3-mm sections of the thyroid in 101 autopsies, they located papillary cancer in 36% of people (Harach HR, Cancer 1985;56(3):531–538). One can imaging that random thyroid biopsies of older individuals will yield a high incidence of thyroid cancer, albeit, of no relevance to survival or morbidity. Unfortunately, the review by Mehanna, lacks clinical perspective and common sense. I suggest reading "Thyroid Nodules: Is It Time to Turn Off the US Machines?" by J Cronan (http://radiology.rsnajnls.org/cgi/content/full/247/3/602) prior to following the proposed clinical guidelines. Competing interests: None declared |
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