• Minimally invasive technique to obtain tissue samples from superficial organs (palpable or not)
• Recommended with ultrasound guidance to improve performance (Cytopathology 2016;27:115, Endocr Pract 2002;8:282)
• In some cases, it can minimize the need for open biopsies for diagnosis
• Can prevent complications associated with surgery for open biopsies
• Performed by many operators across the globe (oncologists, head & neck surgeons, radiologists, other surgeons and some interventional pathologists)
• Different sample gauges can be obtained with automatic and manual devices depending on the type of tissue
• Reporting with protocol templates for interventional procedures is recommended (Rev Esp Patol 2019;52:163)

Contributed by Karen Villar Zarra, M.D.

Contributed by Karen Villar Zarra, M.D.

To be provided

What are the potential complications associated with ultrasound guided core needle biopsy of superficial nodules?

1. Massive hemorrhage
2. Local pain and hematoma
3. Retained foreign body
4. Visual disturbances

B. Local pain and hematoma. Potential complications of ultrasound guided core needle biopsy of superficial nodules include bleeding, hematoma formation, infection, pain or discomfort at the biopsy site, injury to surrounding structures and rarely, pneumothorax in cases involving nodules near the lung or pleura. Answer C is incorrect because in core needle biopsy, only sterile medical devices are used, and under appropriate conditions of sterilization and disinfection, no foreign bodies that may cause adverse reactions are inserted into the body. Answer A is incorrect because bleeding in percutaneous biopsy of superficial nodules is not common. It is considered a low bleeding risk in interventional guidelines due to the possibility of tissue compression even when the lesion is not palpable. Answer D is incorrect because visual disturbances are not expected complications of diagnostic procedures such as FNA and core biopsy.

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Reference: FNA and core biopsy procedure

Which of the following is an advantage of ultrasound guided core needle biopsy over fine needle aspiration for evaluating superficial nodules?

1. Ability to evaluate architectural features and tissue architecture
2. Higher sensitivity in detecting malignancy
3. Less risk of complications, such as hematoma or infection
4. Shorter procedure time and lower cost

A. Ability to evaluate architectural features and tissue architecture. One of the advantages of ultrasound guided core needle biopsy over fine needle aspiration is the ability to evaluate architectural features and tissue architecture. Core biopsy provides larger tissue samples, allowing for a more comprehensive evaluation of the nodule, including the assessment of tissue architecture and the presence of important features such as invasion or encapsulation. Answer B is incorrect because while it is true that in lesions that are indeterminate by FNA, the biopsy provides a more comprehensive assessment of the lesion that can identify malignancy more easily, both techniques can discriminate benign from malignant lesions with good sensitivity. Answer C is incorrect because there is no significant difference between the two procedures in terms of risk of infection; however, it is true that percutaneous biopsy may cause hematoma more frequently than FNA, especially the larger the diameter of the device. Answer D is incorrect because the cost of doing a biopsy is slightly higher than that of doing an FNA, not only because of the use of a different device and additional supplies than an FNA but also because the additional time spent during the procedure may lead to an increase in the cost of the required staff.

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Reference: FNA and core biopsy procedure

What is important to do when performing an ultrasound guided core needle biopsy of a superficial nodule?

1. Administer prophylactic antibiotics to reduce infection risk
2. Apply pressure before the procedure to prevent bleeding
3. Perform a postprocedure ultrasound to evaluate for complications
4. Use a larger gauge needle for improved sample size

C. Perform a postprocedure ultrasound to evaluate for complications. After performing an ultrasound guided core needle biopsy of a superficial nodule, it is important to perform a postprocedure ultrasound to evaluate for potential complications such as hematoma formation or other abnormalities. This helps ensure patient safety and prompt management of any complications that may arise. Answer B is incorrect because pressure should be applied following the procedure and not before it is performed. Answer D is incorrect because using a larger diameter does not mean that a better sample will be obtained; in certain cases, use of a smaller diameter (by increasing the number of cores) may be considered in order to obtain a better representative sample of the lesion. Answer A is incorrect because the use of prophylactic antibiotics is not required to perform core needle procedures.

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Reference: FNA and core biopsy procedure

What is the most appropriate indication for ultrasound guided core needle biopsy of superficial nodules?

1. Nodules > 5 cm in size
2. Nodules with atypical ultrasound features
3. Nodules with high suspicion for malignancy
4. Nodules with typical benign ultrasound features

C. Nodules with high suspicion for malignancy. Ultrasound guided core needle biopsy is a valuable tool for evaluating superficial nodules, particularly when there is a high suspicion for malignancy. Nodules with atypical ultrasound features or those that demonstrate suspicious characteristics such as irregular margins, microcalcifications, increased vascularity, or rapid growth should be considered for biopsy. By targeting nodules with a high likelihood of malignancy, ultrasound guided core needle biopsy can provide important diagnostic information, aid in treatment planning and potentially avoid unnecessary surgical procedures. It is crucial to carefully select nodules with suspicious features for biopsy to optimize diagnostic yield and patient management. Answer D is incorrect because nodules typically benign on ultrasound and with appropriate clinical context, are not chosen for biopsy; in any case, if there is clinical suspicion of malignancy and the ultrasound image is benign, you could start with FNA and then decide whether or not to perform the biopsy. Answer B is incorrect because sometimes there are nodules that can be seen with a pattern suggestive of malignancy on ultrasound and in the appropriate clinical context it may be appropriate to start with FNA to exclude malignancy. For example, a hematoma may have a heterogeneous ultrasound image and be suspicious for malignancy but with a history of local trauma, if FNA is performed and blood is drawn only, there is no need to do a biopsy. Answer A is incorrect because The size of the lesion is not a malignancy criterion in itself. It can be a lesion smaller than 5 cm with suspicion of malignancy that requires a biopsy or it can be a 5 cm nodule with benign FNA and it is not necessary to perform a biopsy.

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Reference: FNA and core biopsy procedure

Contributed by Sadia Sayeed, M.D.

Regarding cervical cytology, which of the following is a known difference observed in liquid based preparation when compared with conventional smears?

1. Larger cell size
2. Larger cellular aggregates
3. Larger nuclear size
4. Nucleoli are less visible
5. Reduction in background blood and inflammation

E. Reduction in background blood and inflammation (Demay: The Art & Science of Cytopathology, 2nd Edition, 2011)

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Reference: Liquid based cytology

A pleural effusion sample has been entirely placed in a ThinPrep vial and processed. A single ThinPrep slide and cell block has been created. The clinical information received with the specimen is "rule out lymphoma". Which known limitation of liquid based preparation applies in this scenario?

1. FISH studies cannot be performed
2. Flow cytometry cannot be performed
3. Immunohistochemistry cannot be performed
4. Microbial culture cannot be performed
5. Molecular testing cannot be performed

B. Flow cytometry cannot be performed. Since the specimen was entirely placed in the methanol based ThinPrep vial, flow cytometry and microbial culture tests cannot be performed. Flow cytometry may be required for diagnosis when the clinical suspicion includes lymphoma. Immunohistochemistry, molecular testing and FISH studies can all be potentially performed on the cell block. In some instances, molecular and FISH testing can be performed on residual sample collected in ThinPrep vials.

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Reference: Liquid based cytology