Chapter 2 FNAC Technique and Slide Preparation 2 Contents 2.1 Informed Consent 2.1 Informed Consent ......................... 7 The ethical and legal requirement to obtain in- 2.2 Location of the FNAC Procedure............ 8 formed consent prior to performing a medical 2.2.1 The FNAC Clinic........................... 9 2.2.2 Inpatient FNAC...........................12 procedure is becoming a mandatory process, 2.2.3 Image-Guided and Other FNAC thus replacing the paternalistic relationship bet- Procedure Locations.......................12 ween doctor and patient that has prevailed for centuries [1]. The patient, after being explained 2.3 The Importance of the Aspirator ...........14 the procedure, its format, purpose, risks, benefits and the alternative approach, makes a voluntary 2.4 Aspiration Techniques ....................15 and informed decision to proceed. The modern 2.4.1 Suction FNAC ............................15 concept of informed consent is a process of mu- 2.4.2 The Capillary Method .....................16 tual communication rather than a signature on a 2.5 Slide Preparation.........................17 standardised form [2, 3]. 2.5.1 Conventional Preparations .................17 The idea of modern informed consent dates 2.5.2 Liquid-Based Preparations .................18 back to 1914 when a judicial ruling stated: “Every 2.5.3 Cell Block................................18 human being of adult years and sound mind has a right to determine what shall be done with his 2.6 Fixation Techniques ......................19 body” [2]. Further legal developments included 2.6.1 Air Drying ...............................19 emphasis on the information given to the patient 2.6.2. Alcohol Fixation ..........................20 2.6.3 Transport Medium ........................20 in order for a decision to be truly informed rat- her than just consented to. The patient should be 2.7 Staining Methods.........................20 allowed the opportunity to ask questions and the 2.7.1 Papanicolaou Staining .....................20 doctor should be satisfied that the patient under- 2.7.2 Romanowsky Staining .....................22 stands what they are signing [4]. Although there 2.7.3 Other Stains ..............................23 are different legal interpretations as to who has a 2.8 Ancillary Techniques .....................23 duty to inform, it is generally accepted that the 2.8.1 Cytochemistry............................23 duty to inform lies with the person who perfor- 2.8.2 Immunocytochemistry ....................24 ms the procedure. 2.8.3 Molecular Markers in Cytology .............26 A consent form usually has two parts, the first part explaining the procedure and the second 2.9 Safety ...................................27 underlining the risks (Fig. 2.1). Both need to be read and understood by the patient prior to the References .....................................28 procedure [5]. It has been shown that twice as many patients read the information leaflet exp- laining the commencement of procedure when information is disseminated in advance rather than on the day of the procedure [6]. It is sug- 8 gested that the consent forms should be written they frequently query the level of pain, invari- in simple terms, using larger print and in du- ably expecting a much more painful procedure plicate copy. Patients should be given copies of than the one subsequently experienced. Concern 2 the consent forms they sign so that they can re- is often voiced as to whether the needle may have read them at home. For true patient autonomy an adverse effect on any pathology, for example to exist in informed consent, patients should be whether it will disseminate a malignant disease. given the form in a language they understand or Sometimes there is a perception that FNAC may else be provided with a competent interpreter be a curative procedure, particularly if the lesion [7]. Patient recall of the list of complications has is cystic. Very few patients understand the rea- been used as a measure of comprehension of the son for the procedure, its place in the diagnostic informed consent procedure [8]. workup or the impact of the result on further management. They frequently confuse the tissue biopsy with the fine-needle biopsy, as FNAC is sometimes known. Pathologists, when obtaining FNAC consent and performing the procedure, are experien- cing a near-patient episode, aspects of which they have not been trained for. They may lack communication skills, which are important in gaining the patient’s confidence. Pathologists oc- cupy a unique place in the management process; they make a diagnosis but do not discuss the re- sults with the patient. This is usually the task of the referring physician. This approach must be explained to the patient in advance of the pro- cedure. Providing information is an important part of the doctor-patient relationship [12]. To that end, informed consent is an integral part of that com- munication. Importantly, it is offering professi- onal protection. Ensuring that all elements of informed consent are met will result in fewer ne- gligence claims, greater patient satisfaction and Fig. 2.1 improved professional image [7]. The process of Sample patient consent form informed consent has led to the empowerment of the patient. The current information revolu- tion is expected to bring further changes in the Aspects of informed consent that are important doctor-patient relationship [1]. to the patient and the doctor include (1) the na- ture of the procedure, (2) the purpose, (3) risks and complications, (4) benefits and (5) alterna- 2.2 Location of the FNAC Procedure tives [9]. Doctors are also interested in the con- sequences of the procedure as regards manage- ment [10]. There are also ethical issues related to One of the advantages of FNAC is that it can be each of these aspects of informed consent. Simi- performed at various locations. Most frequently larly, the patient’s privacy and confidentiality are it is performed in the hospital outpatients de- not to be underestimated [11]. partment, but it can also be performed in hospi- In FNAC practice, patients generally lack tal wards, in a dedicated room within a patholo- knowledge of the procedure. Once explained, gy laboratory or in imaging or endoscopy suites. FNAC Technique and Slide Preparation Chapter 2 9 FNAC need not be confined to the hospital en- procedure being carried out. In cases where the- vironment and may be performed almost any- re is limited space, this recommendation may be where, provided the basic conditions of safety modified in that the accompanying person(s) are satisfied. Using FNAC in rural North West will help to settle the patient and then leave the Australia, Zardawi advocates a multidisciplinary room, to return immediately after the procedure setting with the direct involvement of patholo- is over. In some instances it is advised that there gists, radiologists and clinicians and finds it an should be access to a recovery room in the vici- extremely accurate, well-tolerated, relatively nity of the FNAC room where the patient may be non-invasive and low-risk test that obviates the observed for a short period after the procedure, need for surgical intervention in most benign particularly in cases of bleeding. conditions and disseminated malignancies [13]. 2.2.1 The FNAC Clinic The name FNAC clinic usually refers to the out- patient FNAC service offered to patients with lumps that need investigation. Patients are ini- tially seen by a specialist and are subsequently referred to the FNAC clinic. Patients are usually Fig. 2.2 booked in advance, with a letter of referral or a a A layout of the clinic room with easy access to the request form being available at the time of the examination table from all sides. b The instrument appointment. The minimum staff and equip- trolley should contain all that is necessary for the FNAC ment required for the FNAC clinic room is an procedure assistant (usually a cytotechnologist), an exami- nation couch with access from both sides, a wri- ting desk, a work surface, a microscope, a sink, an examination tray for instruments and good lighting and air conditioning (Fig. 2.2). A cyto- technologist, who puts the patient in the optimal position for the procedure, usually assists the as- pirator. In most cases patients lie on their back, but they may have additional requirements, for example in the case of thyroid FNAC they will have to extend their neck over the support cushion (Fig. 2.3). Patients having difficulty lying flat may remain seated with support or may have Fig. 2.3 the couch elevated to a comfortable position. FNAC for the thyroid is best performed with the Every effort should be made to put the patient patient‘s neck extended over a support at ease, since success of the procedure depends on their cooperation. In some cases, an additi- An FNAC clinic is the ideal place for the aspira- onal chaperone/nurse may be needed to assist tor to obtain a first-hand clinical history. The pa- patients with special needs, for example those tient is usually asked about their symptoms and who are wheelchair bound, poorly mobile, blind any relevant medical history that may not have or children. Patients who wish their partners or been recorded in the referring letter. The anato- companions to be present during the procedu- mical position of the lesion is carefully assessed re are allowed to do so, making sure that they and, subject to the patient’s consent, may be pho- are seated comfortably and not in the way of the tographed in order to gain a more precise insight 10 into the pathology (Fig. 2.4). In the course of examination, particularly after the preliminary microscopy, it may be useful to ask additional 2 questions in reaching a final diagnosis (e.g. is there a history of an excised mole?). Fig. 2.5 Various types of needles available for performing the aspiration. Most frequently used are those of 22 gauge (G) and less Fig.