Gynecologic Needle Biopsy 

Fine-needle aspiration (FNA) is an important diagnostic tool in gynecology. Its main role is in diagnosis of advanced and recurrent gynecologic malignancies. The technique uses a small-gauge needle to aspirate a lesion for cytologic analysis, sometimes with the aid of radiographic imaging techniques.

Ellis and Stuart first described the clinical use of FNA biopsy in the United States in the 1930s. In the 1960s, the procedure was popularized in Europe and Scandinavia as a diagnostic tool for the evaluation of ovarian neoplasms. Although use for this indication has not been considered appropriate in the United States, interest in using FNA for gynecologic tumors was renewed in the 1970s, mainly to evaluate cervical cancer. Since then, the uses of FNA have been refined and expanded in conjunction with modern-day diagnostic imaging to evaluate primary and recurrent gynecologic malignancies.

Use of FNA has been applied to several clinical situations in gynecologic oncology in which results affect treatment (eg, determination of the extent of disease at diagnosis, recurrence). Successful FNA eliminates the need for more extensive diagnostic procedures, such as laparotomy, and thereby reduces cost and morbidity.

A typical clinical case in which FNA provides important information affecting treatment involves advanced cervical cancer, as in the following example case: A 36-year-old patient presented with a clinical stage IIIB squamous cell carcinoma of the cervix, which is typically treated with primary pelvic radiation. Pretreatment CT scan evaluation revealed para-aortic adenopathy, raising concern for metastatic disease. Outpatient CT scan–guided FNA confirmed para-aortic metastasis, and the radiation field was extended to include the para-aortic region.

The major indication for fine-needle aspiration (FNA) relates to diagnosis of either primary malignancy or metastatic disease. In addition, FNA may provide therapeutic benefit in some circumstances. As a diagnostic tool evaluating potentially malignant conditions, FNA is indicated for initial evaluation before treatment and for evaluation for recurrence after therapy.

Initial evaluation before treatment

In general, FNA may be indicated when imaging findings suggest nonfunctional complex ovarian cysts (low risk of malignant disease) and in patients in whom surgery is considered high risk. When performing transvaginal ultrasonographic-guided procedures, using a gynecologic lithotomy stirrups table, which allows for the flexibility in probe position necessary to direct the biopsy needle appropriately, is best.^[1]

FNA can also be used to confirm diagnosis at the primary site (pelvic mass) and to determine the presence of metastasis (eg, lymphadenopathy, parenchymal lesions, ascites, pleural effusion).^[2]

Evaluation for recurrence after therapy

Routine use of FNA for evaluation of a pelvic mass suspected to be ovarian in origin is generally contraindicated, particularly in cystic lesions, secondary to concerns of rupture and potential iatrogenic spread of an isolated malignancy. Also, concerns exist regarding false-negative results, and surgical excision of neoplastic lesions is usually necessary regardless of the cytology.

However, certain clinical situations lend themselves to FNA evaluation of an ovarian lesion. These include metastatic lesions, such as breast or gastrointestinal malignancies, as well as rarer lesions such as lymphomas. In addition, for patients who are not deemed to be surgical candidates, such as those with extensive unresectable intra-abdominal malignancy, FNA may be used to establish a specific histologic diagnosis to direct initial chemotherapy treatment, possibly followed by an interval cytoreductive procedure.^[3]

FNA can be used to evaluate possible metastasis either by direct aspiration of a palpable lesion (supraclavicular or groin node) or in conjunction with imaging modalities such as CT scanning.^[4] As illustrated in the previously mentioned case, findings can influence therapeutic decisions. Pulmonary or hepatic parenchymal lesions are amenable to FNA. Paracentesis in the clinical situation of ascites deserves consideration, although understanding its limitations is important.

In the initial evaluation of ovarian cancer, paracentesis provides little additional information, emphasizing the ultimate need for surgical exploration. In addition, the false-negative rate is high, approaching 50% in the face of advanced disease. The exception to this is paracentesis with the use of neoadjuvant chemotherapy, which is becoming more popular in the United States. Initial use of FNA is generally relegated to providing symptomatic relief of abdominal distention before surgery. Thoracentesis, on the other hand, may be important in establishing the disease stage of ovarian cancer and may be useful in improving pulmonary function preoperatively.

Posttherapy surveillance may incorporate FNA in the evaluation of lymphadenopathy, abdominal or pelvic masses, and abnormal fluid collections, thus eliminating the need for more extensive procedures. This application of FNA has been especially useful in patients with advanced cervical cancer when differentiating radiation effects from recurrent carcinoma is difficult.^[5] FNA may also prove useful in assessment of benign vaginal lesions such as cysts, leiomyomas, and endometriosis.^[6] Culdocentesis, which involves inserting a needle into the peritoneal cavity through the posterior cul-de-sac, once had a potential role in the evaluation of pelvic processes such as ectopic pregnancy and pelvic inflammatory disease. With the availability of laparoscopy and sensitive, readily available tests for serum human chorionic gonadotropin (HCG) levels, its use is now limited.

The safety of fine-needle aspiration (FNA) has been established and is related to small needle size (22-25 gauge), imaging guidance, and appreciation of the surrounding anatomical structures. The relevant anatomy depends on the site in question.

In the pelvis, percutaneous, transvaginal, and transrectal biopsies can be performed; thus, associated anatomical structures, particularly vessels and nerves, must be recognized.

Table. Pelvic Anatomic Considerations (Open Table in a new window)

Other common sites for FNA related to gynecologic malignancy include the supraclavicular and axillary areas, the retroperitoneum, the liver, and the lungs. CT scanning or ultrasonography is generally necessary for deep-seated biopsies to identify the lesion and important related anatomical structures.

Fine-needle aspiration (FNA) has few contraindications. Coagulopathy requires correction prior to the procedure because one of the rare major complications is hemorrhage. Anatomic restrictions must be observed, and guidance by ultrasound or CT scanning may be helpful. Patient tolerance may prohibit FNA being performed in the office setting using local anesthesia, and general or regional anesthesia may therefore be warranted.

As noted, initial evaluation of ovarian lesions with FNA is generally contraindicated, particularly in the perimenopausal or menopausal patient. Lesions in these age groups should be evaluated surgically. Concerns include diagnostic inaccuracy and rupture of malignant cystic lesions with potential spread. In young, carefully selected patients, FNA may be useful, as stated above.