Fine needle aspiration cytology

The importance of the aspirator in obtaining optimal fine needle aspiration (FNA) cytology samples of clinically palpable lesions is an issue that has been discussed in the profession for a long time. From a clinical perspective, it is perfectly understandable and well established that any radiologist or histopathologist prefers reading films or slides produced under standard conditions from their own institution. They would only rarely be persuaded to interpret material from elsewhere. Cytopathologists, on the other hand, have always been happy to accept any FNA material that arrives in the laboratory, regardless of the format and cell preservation, provided it is well labelled. This readiness on the part of cytopathologists has resulted in a relatively high threshold of non-acceptable material, possibly due to the fear of rejection and possibly due to the irresistible challenge of making a diagnosis on the basis of minimal available evidence. In our eagerness to promote FNA amongst clinicians as an easy, cost effective, relatively painless and ambulatory procedure, cytopathologists have often, actively or passively, encouraged those who were prepared to try their hand at taking FNAs, sometimes after no more than a set of instructions over the telephone. Badly taken samples are repeatedly tolerated, often with considerable frustration but without any formal action. Clinical management dilemmas arising from inadequate FNA samples are well described. What has changed in the past 30 years? The big difference between now and the pioneering times when FNA was still gaining acceptance is that the expectation of its performance is now much greater. There have been many published FNA series that claim high degrees of diagnostic accuracy, often ignoring inadequate rates. Pathologists in smaller institutions cannot justify poor FNA results compared to those reported in the literature. Persisting tolerance of FNA malpractice caused by technically poor preparation has been exposed in many medico-legal cases as the main reason for diagnostic failure. Resulting direct comparisons of FNA cytology with core biopsy are often inappropriate. In good hands FNA remains a first line investigation to be followed by more aggressive means later, if necessary. Two papers in this current issue illustrate the above points, showing how, many years after introduction, FNA still fails to achieve the highest degree of sensitivity due to inadequate samples. Singh et al. (please insert pages into the reference) analyse their FNA results in the setting of a breast clinic and find that the difference in performance between cytopathologists and non-cytopathologists is almost threefold in favour of cytopathologists. Pleat et al. (please insert page into the reference) do a similar survey in surgical outpatients and find that the inadequacy rate, amounting to almost half of the cases, improves dramatically after training of the aspirators. These papers illustrate that the only way for FNA to be performed is by a limited number of trained aspirators. In some instances, this may be a pathologist, in others a radiologist or a surgeon. It is unrealistic to expect conformity in this respect since practices vary. Many of the pathologists who practice cytopathology and who could make a difference to the quality of the sample still believe that the pathologist’s place is not by the bedside but in the laboratory and at the autopsy. Some are reluctant to see patients. However, they are missing a gratifying opportunity of taking part in clinical medicine. Having been trained in macroscopic as well as microscopic appearances of disease and site specific pathology, and having insight into current methodologies which require specimen handling in a way that was not previously possible, pathologists are in an ideal position to perform FNAs on palpable lesions. Can we expect our failings to be helped by new technologies? All expectations are currently with liquid based cytology (LBC) and what it promises in terms of reducing inadequacy rates, particularly in gynaecological cytology. There is a place for the use of LBC for non-cervical cytology. Whilst it will undoubtedly offer the possibility of adjunctive analyses on FNA material, LBC may not cover up incompetence at taking FNA samples. FNA technique is simple but not banal. It requires a certain manual dexterity in the same way as surgical procedures do. These need to be acquired prior to proceeding to take diagnostic samples. Teaching aids