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The Procedure of Ultrasound-Guided Percutaneous Biopsy of Thyroid and Cervical Lymph Nodes: Technical Steps, Pitfalls, and Pearls

  • Robert A. LevineEmail author
  • John InterlandiEmail author
Chapter

Abstract

This chapter focuses on the hands-on techniques of ultrasound-guided fine needle aspiration (USGFNA) of the thyroid and cervical lymph nodes. A preliminary discussion on US selection of nodules for USGFNA, patient preparation, informed consent, and the biopsy-planning ultrasound set the stage for the procedure. The technical sections review local anesthesia for USFNA, biopsy techniques, and choices of ultrasound orientation. Difficult biopsy situations and complications are discussed. Slide preparation and on-site adequacy assessment are reviewed. Techniques of USGFNA of cervical lymph nodes are discussed.

Keywords

Ultrasound guided biopsy Fine needle aspiration biopsy Thyroid nodules Thyroid cancer Suction biopsy Suctionless biopsy Capillary biopsy Parallel technique Perpendicular technique 

Supplementary material

Video 28.1

Suctionless biopsy using needle alone. Note that the skin is punctured quickly and the needle then slowly advance to the target. A combination of rotation and oscillation is then employed (MP4 9884 kb)

Video 28.2

Suctionless biopsy using needle alone. Note that the skin is punctured quickly and the needle then slowly advance to the target. A combination of rotation and oscillation is then employed (MP4 7252 kb)

Video 28.3

Suctionless biopsy with syringe barrel. Similar to the technique shown in Videos 28.1 and 28.2, in this technique, the needle is attached to a syringe with the plunger removed. This allows a “pencil grip” and may allow better dexterity (MP4 7137 kb)

Video 28.4

Suctionless biopsy with syringe barrel. Similar to the technique shown in Videos 28.1 and 28.2, in this technique, the needle is attached to a syringe with the plunger removed. This allows a “pencil grip” and may allow better dexterity (MP4 9208 kb)

Video 28.5

Biopsy with assistant. If suction is needed and a suction device is unavailable, the operator can hand off the transducer to an assistant, freeing up both hands to perform the section and a biopsy (MP4 8757 kb)

Video 28.6

Extension tubing for suction. The simplest approach to applying suction is to place the needle on one end of extension tubing, and have the assistant pull back on the syringe, attached to the other end of the extension tubing. This technique is used for draining cysts. For solid tissue biopsy 1–2 mL of negative pressure should be applied. The section should be released prior to removing the needle from the patient’s neck (MP4 14,817 kb)

Video 28.7

Tao Aspirator. The Tao aspirator is a spring-loaded device that allows suction to be applied after the needle tip is in the area of interest. It is currently out of production (MP4 14,533 kb)

Video 28.8

Tao Aspirator. The Tao aspirator is a spring-loaded device that allows suction to be applied after the needle tip is in the area of interest. It is currently out of production (MP4 10,252 kb)

Video 28.9a

(a, b) Additional suction device 1. Other devices are available to allow application of suction after the needle is in the area of interest. In this device, two plungers are available, one to apply section, and one to expel contents of the syringe. The needle is inserted into the area of interest and suction is applied by pressing on the appropriate plunger (MP4 4917 kb)

Video 28.9b

(a, b) Additional suction device 1. Other devices are available to allow application of suction after the needle is in the area of interest. In this device, two plungers are available, one to apply section, and one to expel contents of the syringe. The needle is inserted into the area of interest and suction is applied by pressing on the appropriate plunger (MP4 4917 kb)

Video 28.10

Angiographic syringe. An angiographic syringe allows for suction to be applied using the thumb (MP4 5668 kb)

Video 28.11

Parallel screen view 1. An example of the monitor view during a parallel biopsy. The needle is visualized throughout the entire biopsy, and the needle tip is observed to be within the nodule at all times (MP4 6071 kb)

Video 28.12

Parallel screen view 2. An example of the monitor view during a parallel biopsy. The needle is visualized throughout the entire biopsy, and the needle tip is observed to be within the nodule at all times. Note that the needle is directed near the area of calcification (MP4 6161 kb)

Video 28.13

Perpendicular screen view. In the perpendicular view, the needle tip is seen only when the bevel traverses the ultrasound beam (MP4 5791 kb)

Video 28.14

Curvilinear transducer biopsy. The probe is placed directly over the target and the target is centered within the ultrasound screen. The probe is then slid laterally and rotated medially, continuing to point toward the target. The needle is then introduced directly perpendicular to the skin, aiming straight down from the prior initial center of the ultrasound probe. This results in the needle entering the target (MP4 13,194 kb)

Video 28.15a

(a, b) Spinal needle for deep biopsy. The needle is advanced until within the target, and the assistant removes the stylet, with sampling beginning at that time (MP4 2258 kb)

Video 28.15b

(a, b) Spinal needle for deep biopsy. The needle is advanced until within the target, and the assistant removes the stylet, with sampling beginning at that time (MP4 2258 kb)

Video 28.16

Smear technique 1. In the typical smear technique, the second microscope slide is introduced in a perpendicular dimension and contact is made between the edge of the slide and the below the target on the index slide. The top slide is then lightly and gradually lowered until it lightly makes contact with the sample, at which time it is lightly dragged down, avoiding crush artifact (MP4 3005 kb)

Video 28.17

Smear technique 1. In the typical smear technique, the second microscope slide is introduced in a perpendicular dimension and contact is made between the edge of the slide and the below the target on the index slide. The top slide is then lightly and gradually lowered until it lightly makes contact with the sample, at which time it is lightly dragged down, avoiding crush artifact (MP4 2413 kb)

Video 28.18

Smear technique 1. In the typical smear technique, the second microscope slide is introduced in a perpendicular dimension and contact is made between the edge of the slide and the below the target on the index slide. The top slide is then lightly and gradually lowered until it lightly makes contact with the sample, at which time it is lightly dragged down, avoiding crush artifact (MP4 6196 kb)

Video 28.19

Bookends smear technique. An alternative method of slide preparation is referred to as “bookends.” In this technique the second slide is lightly placed in a parallel orientation to the first and capillary action spreads the sample out over the slides. They are then separated as in opening a book. This technique provides two slides with “mirror image” samples. The first slide may be used for rapid on-site assessment, and the second slide can be used for definitive staining (MP4 64,553 kb)

Video 28.20

Bookends smear technique. An alternative method of slide preparation is referred to as “bookends.” In this technique, the second slide is lightly placed in a parallel orientation to the first and capillary action spreads the sample out over the slides. They are then separated as in opening a book. This technique provides two slides with “mirror image” samples. The first slide may be used for rapid on-site assessment, and the second slide can be used for definitive staining (MP4 3960 kb)

Video 28.21

Flick technique for sample extraction. If sample material is stuck in the hub of the needle, it can be extracted by “flicking” the needle as shown. In this demonstration the needle is placed into the rubber stopper of a vacuum tube. An alternative is to carefully grip the needle with a hemostat or needle driver (MP4 9068 kb)

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Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Thyroid Center of New Hampshire, St. Joseph Hospital EndocrinologyNashuaUSA
  2. 2.Department of EndocrinologyAdvanced Health PartnersHermitageUSA

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