College of American Pathologists
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  Ultrasound in the FNA clinic—how to get started


CAP Today




August 2011
Cytopathology And More

Cynthia C. Benedict, MD
Rosemary H. Tambouret, MD

Susan D. Rollins, MD, shared in these pages, in August 2008, her experience as an interventional cytopathologist in her clinic in Johnson City, Tenn. Here, this month, is additional information for those cytopathologists interested in testing the ultrasound waters.

One way to get started is to request observation sessions with clinicians in your institution who are using ultrasound to perform fine-needle aspirations, especially interventional radiologists, endocrinologists, and breast surgeons. Observing a variety of clinicians using ultrasound is necessary to ensure exposure to all the anatomic sites (lymph nodes, salivary glands, thyroid glands, breast, soft tissue) normally encountered in a cytopathologist-run FNA service. These times when you’re observing can be mutually beneficial. You will get the lowdown on needle placement technique and instrumentation, and the clinician will get tips from you on slide smearing technique, cell block preparation, and other details of sample preparation. In some institutions, the relationship between the cytopathologist and clinician is such that the cytopathologist is offered the use of the clinical ultrasound equipment to examine the cytology patients. This is especially helpful if an ultrasound technician is also available to assist the pathologist.

Another possibility is to participate in a hands-on ultrasound-guided FNA course offered by one of the professional medical societies. As part of its new series of transformative educational programs, the CAP offers the Ultrasound-Guided Fine-Needle Aspiration Advanced Practical Pathology Program (USFNA AP3). The two-day workshop, designed for pathologists who already perform FNA, is held several times a year at the CAP in Northfield, Ill., and consists of small-group, hands-on training in the ultrasound-guided FNA technique. A pre-course self-study module is designed to prepare the participants for the course. The course faculty members are experienced in USFNA and come from academic and private practice settings. Topics include ultrasound physics, pertinent anatomy, interpretation of ultrasound images, use of ultrasound equipment including needle placement in phantom devices, and cytology sample preparation. A certificate is issued once the practical assessments of needle placement and slide smearing technique, and the cognitive assessment, are completed satisfactorily. This USFNA program in May received an Excellence in Practice Citation from the American Society for Training and Development; it was presented at the International Conference and Exposition in Orlando, Fla. To learn more about the course, go to

Another way to integrate ultrasound into the FNA clinic is to purchase one of the many small ultrasound devices on the market. The vendors will often allow you to borrow an ultrasound machine for demonstration purposes, provide sessions on how to use the equipment, assist with installation, including presets for your most common exams, and assist with integration into your computer network, if needed.

Finally, several excellent articles that provide an overview of the burgeoning field of point-of-care ultrasound and ultrasound-guided FNA have appeared in the literature recently. Moore and Copel provide an overview of point-of-care ultrasound in medicine, but interestingly fail to include pathologists in their list of clinicians using ultrasound.1 David Lieu, a cytopathologist with his own freestanding FNA clinic in Los Angeles, has published a primer on the physics of ultrasound for pathologists and a separate series of ultrasound-guided parathyroid aspirates performed in his practice.2,3 Dr. Lieu’s publications illustrate the practical and academic interest in the performance of ultrasound-guided FNAs.


1. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011; 364:749–757.

2. Lieu D. Ultrasound physics and instrumentation for pathologists. Arch Pathol Lab Med. 2010;134:1541–1556.

3. Lieu D. Cytopathologist-performed ultrasound-guided fine-needle aspir-ation of parathyroid lesions. Diagn Cytopathol. 2010;38:327–332.

Dr. Benedict, a member of the CAP Cytopathology Committee, is a staff pathologist and director of the fine needle biopsy clinic at DCL Pathology, Indianapolis, Ind. Dr. Tambouret, a member of the CAP Cytopathology Committee, is in the Department of Pathology, Massachusetts General Hospital, Boston.

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The USFNA Advanced Practical Pathology Program (USFNA AP3 ) workshop, March 10–12, 2012, San Francisco, California, provides board-certified pathologists with the opportunity to master specialized FNA biopsies breast and thyroid biopsies using soft-tissue phantoms. Participants also gain the essential background to introduce USFNA services at their institutions.
Learn more. Register.