DIRECTFINE NEEDLE ASPIRATIONCYTOLOGY To the Editor: After reading the article on unguided fine needle aspiration cytology by Edoute et al [l], the reader may erroneously conclude that unguided abdominal aspirations can be performed by inexperienced clinicians with impunity, since according to the authors, the two cases eventuating in serious complications “could have been avoided if patients were carefully selected and meticulous attention was paid to the implementation of proper procedures.” The authors then fail to elaborate or to indicate how patients should be selected and what constitutes proper procedure. What the authors purposefully fail to indicate is that under some circumstances, proper procedure is computed tomographic (CT) guidance, and the approach they advocate--unguided, direct aspiration-is not only not indicated, but is unsafe. Reported complications of fine needle aspiration include death, exsanguination, and peritonitis [2-41. Of great importance is avoiding transgressing the colon during the procedure, as illustrated by the following example. A pathologist inexperienced in fine needle aspiration performed an unguided procedure at a local hospital. Between the large, necrotic abdominal tumor and the skin was a thickened, diseased colon, adherent to the tumor. In transgressing the colon, the pathologist inoculated feces into the tumor. The patient, as a direct result of the procedure, developed a large intra-abdominal abscess, multiple fistulas, and peritonitis, and subsequently died of sepsis. This horrible scenario could have been avoided by CT guidance, which would have

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permitted aspiration ionic transgression.

without

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ED WARDS. ACKERMAN,M.D. Catholic Medical Center Manchester, New Hampshire 1. Edoute Y. Ben-Haim SA. Malberger E. Value of direct fine needle aspirative cytology in diagnosing palpable abdominal masses. Am J Med 1991: 91: 377-82. 2 Yankaskas B, Staab E, Craven M, Watt dan M, Carney C. Delayed complications needle biopsies of solid masses of the Invest Radio1 1986; 21: 325-8. 3. Livraghi T, Damascelli B, Lombardi C, Risk in fine-needle abdominal biopsy. J

wund

P, Sokhanfrom fineabdomen. Spagnoli I. Clin Ultra-

1983; 11: 77-81.

4.Mueller P, Ferruci biopsy of abdominal

J Jr. Fine needle aspiration masses. Semin Roentgenol

1981; 16: 52-61. Submitted

December

12, 1991, and accepted February 19, 1992

The Reply: We thank Dr. Ackerman for his remarks regarding our article and would like to respond to the comments that he raised. 1. Nonguided fine needle aspiration (FNA) of palpable lesions for cytologic examination is a simple, inexpensive, safe, and highly accurate method for diagnosing the nature of the lesion [l-4]. The reliability and the technical perfection of aspirative cytology depend on the skill of the performer. Although FNA is a simple procedure, we want to emphasize that direct (nonimaging-guided) as well as imagingguided FNA of any target lesion should be carried out only by an experienced performer. Naturally, the less experienced performer is more likely to encounter complications. 2. Although a number of reviews confirmed the safety of FNA, major complications and even fatalities, although rare, can and do occur [5-3]. Therefore, it is important to be aware of the possibility, and to take all the appropriate precautions in order to prevent or to reduce their incidence. When direct FNA of a palpable abdominal mass was ini-

July 1992 The American Journal of Medlclne

Volume 93

tially introduced in our medical center, we had two major nonfatal complications. In one jaundiced patient, bile peritonitis followed erroneous aspiration of an unresected distended gallbladder. In the other patient, localized peritonitis and abdominal wall infection developed after the improper performance of FNA, with aspirated sigmoid contents infecting the needle’s tract. Retrospectively, these complications could have been avoided if precautions had been taken, and if aspiration had been conducted correctly [7]. We hereby define our requirements for proper procedure. A. Proper selection of patients. In the case of a palpable mass in the right upper quadrant in a jaundiced patient, a distended gallbladder should be excluded before FNA is performed, otherwise, bile peritonitis may be expected [7]. In addition, we would like to emphasize that hemorrhagic diathesis is a contraindication for FNA. Since chronic disseminated intravasular coagulation (DIC) with enhanced fibrinolysis secondary to malignancy may induce hemoperitoneum, FNA should not be performed until hemostatic evaluation (including platelet count, prothrombin time, partial thromboplastin time, and D-dimers) has excluded DIC [8]. B. Proper technique of FNA. We perform FNA of a palpable mass using a 23-gauge needle without anesthesia. As the aspiration is intended to obtain cellular materials only, the lumen of the fine needle is ample. The dislodging of cellular material from solid masses is achieved by means of negative pressure from the aspirating syringe. The needle is attached to a 20-mL disposable syringe, mounted on a special handle designed for this purpose. After the skin is wiped with an