In This Article
- During the COVID-19 pandemic, clinics are implementing new precautions and encouraging patients to seek care
- The Fine-Needle Aspiration Biopsy Service at Massachusetts General Hospital is preparing to reopen with new safety protocols in place
- Martha Pitman MD, director of the service, discusses the groundbreaking work taking place at the clinic and shares their new safety protocols
Uncertainty surrounding the COVID-19 pandemic has led many people to postpone important medical care—often to their detriment. As clinics reopen and restructure in our post-COVID world, many are taking critical precautions to ensure they can safely encourage patients to seek care.
Pathologist Martha Pitman, MD, is the director of the Fine-Needle Aspiration Biopsy (FNAB) Clinic at Massachusetts General Hospital and the Mass General Cancer Center. She and her team are preparing to reopen the FNAB clinic under new protocols, enabling them to provide their cutting-edge treatment while limiting patients' COVID-19 exposure risk.
In this Q&A, Dr. Pitman discusses the work she and her team are doing with the FNAB Clinic and the precautions they're taking as they reopen.
Q: Can you describe the work you do at the FNAB?
Pitman: The FNAB Clinic is a Mass General-based, pathologist-run biopsy clinic where we see patients with superficial masses that need a diagnosis. As interventional cytopathologists, we are able to evaluate a mass, biopsy the mass with a fine needle and perform rapid onsite evaluation (ROSE) of the FNA at the time of the biopsy. ROSE allows the cytopathologist to triage the tissue for ancillary studies if needed including flow cytometry and genetic analysis. ROSE also allows the referring physician to quickly coordinate further patient care. The clinic has been closed since March 25 due to the COVID 19 pandemic, but will reopen on June 29.
Q: What COVID-19-related precautions are you taking as you reopen the clinic?
Pitman: Patients must wear a mask during the procedure and wash their hands for 20 seconds prior to being seated for the FNA. Family members will not be allowed in the room during the biopsy. The interventional cytopathologist must wear a procedural mask at all times and a face shield during the procedure. If an FNA is performed on a patient with respiratory symptoms, someone who is COVID-19 positive or someone who is at COVID-19 infection risk, it must be performed in a RACC (routine ambulatory clinic) with full personal protective equipment, and this will need to be arranged by the requesting physician. The FNA procedure room is thoroughly cleaned and disinfected between procedures.
Q: What are the advantages of FNA?
Pitman: FNAs are fast, relatively inexpensive and safe. Small (23-25 g) needles are used to aspirate cells from the mass for diagnosis and ancillary testing. The risks include a bruise, hematoma and infection, but these risks are extremely low. Needle track seeding is virtually unheard of with such small needles. The limitation of an FNA is primarily sampling error, which is the primary reason for a false negative biopsy. Not all masses provide tissue easily and not all tissue is diagnostic of the lesion (e.g., fat from a lipoma, blood from a hemangioma, scant fibrous tissue from a scar, etc.).
False positive results are extremely rare. The results of the FNA must be interpreted in the context of the clinical presentation. Further evaluation with a core or excisional biopsy is warranted for any case where the "triple test" (physical exam, imaging and tissue results) do not match.
Q: When should a physician refer a patient to the FNAB clinic?
Pitman: Patients with superficial masses of the head and neck (salivary glands, cervical lymph nodes, thyroid gland), breast, soft tissue, lymph nodes of the groin and axilla and skin (subcutaneous masses) are seen in the FNA Biopsy Clinic. Fat pad biopsies screening for amyloidosis are also performed. Ultrasound is available to the interventional cytopathologist to assess the characteristics of the mass and guide the needle if needed.
The fastest and easiest method to request an FNA is to call cytopathology and FNA at 617-726-3980. A Mass General Fine Needle Aspiration Service referral order method in EPIC is currently being developed.
Q: How do you work with a referring provider once you've evaluated the biopsy cells?
Pitman: The interventional cytopathologist will call, text or email the referring physician with the ROSE results following the procedure. A final report following examination of all slides and any ancillary studies will be provided in EPIC within 24 to 48 hours in most cases. This report includes the final diagnosis and an addendum of the evaluation and management report including the physical exam, ultrasound findings and procedure notes.
Q: Why should a clinician (and a patient) choose the Mass General FNA Biopsy clinic for a biopsy?
Pitman: The FNAB Clinic is a point of care diagnostic service run by interventional cytopathologists who are trained in the technique and the interpretation of the biopsy at the patient's side. This allows for immediate assessment of the specimen for adequacy, thus precluding a nondiagnostic biopsy, which would necessitate bringing the patient back for a repeat procedure and delaying care. Same day appointments also help with rapid diagnosis and coordination of care and is especially convenient for patients from out of town. Many FNAs are also performed for peace of mind when clinical suspicion is low as it adds the third component of the "triple test," i.e., tissue evaluation.
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