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8/13/2019 FNAB Final
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F N BonMusculoskeletal Tumor
Fathurachman
Oncology Section
Dept. of Orthopaedic & Traumatology
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Prologue
Musculoskeletal tumor
Multi-discipline approach
Systematic steps
FNAB: alternative method
Major role on Dx & Tx
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FNAB, Technical
Development FNAB on tumors that had a classic
radiographic appearance
Role: a confirmatory test FNAB: for previously undiagnosed
orthopaedic masses and tumors
FNAB is most successfully
Confirming the clinicoradiographicdiagnosis
In a patient whose tumor has classicpresentation
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FNAB, Technical
Development 20- to 40-year-old age
group
A distal femoral orproximal tibial lytic,eccentric, geographic,subchondralepiphyseal lesion
Almost certainly has aGCT
FNAB is excellent atconfirming thediagnosis of GCT ofbone
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FNAB, Technical
Development FNAB is an integral component of an
overall team approach
Team includes:Orthopaedic oncologistMedical oncologist
Radiologists
Pathologists The pathologists must be skillful in
the cytopathologic interpretation oforthopaedic tumor aspirates
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FNAB, Technical
Development Multiple advantages compared to
open biopsy
It is quick, inexpensive, andminimally invasive
Performed on the day of the initialoffice visit
To establish the diagnosis ofosteosarcomas at less than onefourth the cost of open biopsy
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FNAB, Technical
Development Without any anesthesia
Minimal to no discomfort
Well tolerated by patients
23- or 25-gauge needle
Diagnostic aspiration biopsiesobviate the need for open
biopsies
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FNAB, Technical
Development This allows surgery to proceed
expeditiously
Confirmed preoperative diagnosis
Avoids the need to wait for the pathologists to
process the frozen section intraoperatively
Alternatively, should an osteo-sarcoma be
diagnosed at FNAB
Then the appropriate systemic evaluation andchemotherapy can be initiated quickly
Without having to schedule and perform an open
procedure
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FNAB, Technical
Development FNAB is successful in the diagnosis
of bone malignancies
Highly accurate in diagnosingosteosarcoma, myeloma, andEwing's sarcoma as well as otherbony sarcomas
FNAB can correctly identify bonysarcomas in 93% of cases
Histogenetic subtyping can beachieved in approximately 82% of
these same cases
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FNAB, Technical
Development Negative for malignancy" or that
"contains no malignant cells" doesnot absolutelyconfirm the absenceof malignancy
It simply means that: no identifiablemalignant cells were aspiratedandexpelled onto the glass slide
Due to non-representative sampling
To the needle having missed thelesion altogether
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FNAB, Technical
Development To the absence of a malignant entity
Therefore, a "negative" FNAB: onecomponent of an overall diagnostic picture
Deeper lesions: imaging guided FNAB canavoid a false-negative finding due to theneedle missing the lesion
If the cytologic findings and interpretations
are not consistent with the clinical andradiographic findings and a malignancy issuspected, then open biopsy or coreneedle biopsy is indicated
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Materials
Performed in the outpatient setting
Inpatients as well
A mobile cart containing:The appropriate stains
Glass slides
Syringes
Syringe holder
Double-headed microscope
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Before Procedure
The attending pathologist, surgeon
and musculoskeletal radiologist
typically review:Plain radiographs
CT scans
MRI scans
Bone scans
Other appropriate clinical,
laboratory, and radiographic data
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Procedure
Prepared with povidone iodine
No local anesthetic
A 25-gauge needle on a 20-ccsyringe containing 5 cc of air isadvanced through the skin into thetumor
The plunger on the syringe is thenwithdrawn fully, creating anadditional 15 cc of vacated potentialair space within the syringe and a
vacuum at the needle tip
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Procedure
The needle is then rapidly and
sequentially advanced andwithdrawnwithin the tumor mass inmultiple directionsto provide arepresentative sample from multiple
areas within the tumor
Ideally, this procedure is performedthrough one puncture sitewithin thetumor wall
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Procedure
Once the aspiration passes within thetumor have been completed, the negativepressure is released and the plunger
returns to the 5-cc position in the syringewith 5 cc of air remaining in the syringe
The needle is then withdrawn from thepatient
An assistant maintains pressure on thearea for a minimum of 5 minutes to preventtumor bleeding and local tumor spread
The aspirated specimen typically fills onlythe hub of the needle
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Procedure
Rarely, with a bloody specimen, asmall amount of bloody tissuesufficient to reach to the channel ofthe syringe is obtained
The sample of aspirated material isexpressed onto glass slides utilizingthe retained 5 cc of air in the syringeto expel the specimen
The material is then smeared with asecond glass slide
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Procedure
And one smear is air dried andstained:
Diff-Quik (Fisher ScientificBiomedical Sciences, Inc,Swedesboro, NJ)
The other slide is immediately
immersed in 95% ethanol forsubsequent staining by thePapanicolaou method
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Interpretation
Knowledge of
normal bone &
marrow cells
On smear:
Megakaryocyte
Osteoblast
Osteoclast
Chondroblast Osteoid matrix
Chondroid matrix
Normal bone &
cartilage
Primary &secondary tumor
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Interpretation
Secondary tumor: foreign
structure
Matrix (+):Primary tumor
Reactive lesion
Benign
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Interpretation
Soft tissue malignancy
Difficult
Overlapping feature of cells &
tissue
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Interpretation
Lowhagen & Skoog, Karolinska Hosp.,
Sweden:
1. Soft tissue origin, not a reactive lesion,inflammation, degenerative,
metastatic, lymphoma
2. Soft tissue tumor, benign or malignant?
3. Malignant tumor, low or high grade?
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From: Lunardhi, J.H., in : Fine needle aspiration cytology in
musculoskeletal pathology, Proceeding of Scientific Meeting &
Workshop of Indonesian Musculoskeletal Pathology, Surabaya,
22-23 March 2003
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Further Analysis
Sophisticated analysis
Immunocytochemical
Electron microscope
Chromosome analysis
Molecular analysis
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Summary
Accurate diagnostic information
Help clinician to decide
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