<ol style="list-style-type:upper-alpha;">
<li>Preparation of phantom lesion (prepare phantom about 38 to 48 hours prior to actual practicing session of FNA proficiency (Figure 1) or utilize ready to use 'AV Phantom' from FNA Source, USA. The phantom lesion (stored under refrigeration without freezing) may be kept prepared even 3 to 4 days prior to practice session.</li>
<li>Practicing FNA proficiency: Although we have demonstrated the procedure using Shidham's THFV (Tissue Harvester with Functional Valve) (FNA Source, USA), any other FNA system may be used for practicing (Figure 2).</li>
<li>Spreading and processing the aspirate on the glass slides (Figure 3).</li>
</ol>
Material required
<ol style="list-style-type:lower-alpha;">
<li>Clear silicone rubber caulk- available at many construction/home improvement stores. Many brands are available including GETM, DAP, Red Devil, White Lightning, and local chain brands. We used Clear Silicone Rubber, White Lightning Products, Cleveland, Ohio, USA, <a href="http://www.wlcaulk.com/products/all_purpose/silicone_rubber/wl09010.html">http://www.wlcaulk.com/products/all_purpose/silicone_rubber/wl09010.html</a>)</li>
<li>Caulking gun</li>
<li>A piece of plastic wrap sheet (we used Saran Cling Plus Wrap, SC Johnson &amp; Son Inc, Racine, WI, USA <a href="http://www.saranbrands.com/plastic-wrap/index.asp">http://www.saranbrands.com/plastic-wrap/index.asp</a></li>
<li>Latex gloves</li>
<li>Wide diameter banana or sausage.</li>
<li>Firm and flat base plate (approximately 6 inches X 6 inches) made of thick card board, acrylic plate, or other.</li>
<li>FNA performing equipments 
<ul>
<li>25 gauge hypodermic needles</li>
<li>Shidham's THFV (or other components for performing FNA)</li>
<li>glass slides</li>
<li>staining kits</li>
</ul>
</li>
</ol>
Step-by-step details
A. Preparation of phantom lesion (prepare phantom 1 to 2 days prior to practicing FNA proficiency (Figure 2) or utilize ready to use 'AV Phantom' from FNA Source, USA.
<ol>
<li>Cut a 6 X 6 inch size of supporting board.</li>
<li>Cut a 2.5 inch long segment of 'phantom lesion core' (banana or sausage).</li>
<li>Expel 0.5 inch thick layer of caulk on the base plate.</li>
<li>Press the 'phantom lesion core' lightly in to this layer of caulk. </li>
<li>Add more caulk over the 'phantom lesion core' so that it is completely embedded in the mound of caulk, without trapping air bubbles.</li>
<li>Adjust and shape the caulk over 'phantom lesion core' with gloved hand.</li>
<li>Take a 6 X 6 inch size piece of plastic wrap and cover the caulk mound and adjust the surface of the mound into a smooth convex configuration with a clean, gloved hand.</li>
<li>Let the caulk mound cure for 6-8 hours longer than the curing time mentioned under the product instructions, (usually for 24 hours), in warm place.</li>
<li>After curing, the caulk should be firm, and the plastic wrap can be peeled off easily.</li>
<li>The FNA phantom lesion is ready to be used for practicing the FNA procedure after about 8 hours when the entire mound of caulk has completely cured  to the center containing the 'phantom lesion core' (banana or sausage).</li>
</ol>
B. Practicing FNA proficiency on AV Phantom lesion.
Any approach in obtaining high quality, adequate FNA aspirates with good quality direct cytology smears should address following critical points-
<ol style="list-style-type:upper-roman;">
<li>The needle gauge- as implied in the title of the procedure, the finer needles (higher gauge number) yield better aspirates with minimal blood dilution. For critical balance of benefits and limitations, 22 to 25 gauge needles are preferred for optimal mechanical stability of the needle without affecting the FNA aspirate quality.</li>
<li>Controlling appropriate sequences in vacuum application and release during the FNA procedure- This is critical in order to advance the sampled cells with each stroke of the needle, towards the needle hub. However, the aspirated material should not be allowed to reach into the area of the needle aspiration assembly with syringe. If this is not prevented, the material may be difficult to retrieve for making smears (this material may, however, be used for cell block preparation or for concentration methods such as Cytospin, filter methods, or recent liquid based cytology preparations).</li>
<li>Developing appropriate skill in processing of the aspirated specimen, including direct smear preparation and on-site adequacy evaluation with appropriate triaging for ancillary tests such as cell-block preparation for elective immunocytochemistry, elective flow cytometry for immunophenotyping of lymphoproliferative lesions, submitting sterile passes for microbiology studies, and material for molecular tests (cytogenetics, etc.).</li>
</ol>
Ba. Performing FNA procedure (shown with Shidham's THFV [1] (FNA Source, USA); however, any other FNA system may be used for practicing) (Figure 3,4,5).
<ol>
<li>Prepare the FNA assembly with the valve closed. </li>
<li>Locate the lesion and insert the needle tip in the lesion.</li>
<li>Open the valve to connect the vacuum, through the needle to its tip, to aspirate representative cellular components of the lesion with each to and fro stroke into the lesion.</li>
<li>Maintain the vacuum and sample different areas of the lesion by inserting the needle into the lesion in different directions.</li>
<li>Close the valve to disconnect the vacuum in the needle lumen.</li>
<li>Equalize the pressure with ambient conditions (E.g. by disconnecting the Syringe-valve from the needle for a brief moment &amp; reconnect. If the special device with inbuilt steps, such as 'THFV' is used, this and other steps from Ba1 through Ba6 are concerted automatically by following different steps in the valve system) [1].</li>
<li>Remove the needle from the lesion with the valve closed, in order to prevent loss of the specimen by capillary action into the lesion unless there is slightly negative pressure at the hub end.</li>
<li>Dislodge the aspirated content onto the glass slide to prepare direct smear (see below) (figure 6).</li>
</ol>
Bb. Processing of the aspirated specimen with appropriate triage 
Spreading the aspirate on the glass slides and preparing good quality direct smears (Figure 6) followed by proper staining and triage (Figure 7,8).
<ol>
<li>A drop of aspirate dislodged on the glass slide is spread by a variety of approaches as shown in (Figure 6) [2]. The usual approach is 'a'. However, if the specimen is blood diluted with some microfragments, the excess blood is drained away by tilting the slide, and the microfragments then are spread between this slide and second glass slide similar to 'a'. If the aspirate is predominantly a suspension without microfragments, such as from lymphoproliferative lesions, it is spread similar to 'b' or 'c'.</li>
<li>The smears may be processed and fixed in variety of ways for different staining methods during on-site adequacy evaluation. However, the best approach is to air-dry all the smears. The air-dried smears can be stained with Romanowski stains (such as Difff-Quik stain, Wright stain) after methanol fixation or with Pap stain after saline-rehydration and post-fixation (in 95% ethanol or preferably in 95% ethanol with 5% acetic acid) [3]. Elimination of interference due to the obscuring blood is a significant benefit [3].</li>
<li>Depending on the initial cytomorphologic findings during on-site adequacy evaluation, additional triage (such as elective cell block, electron microscopy, microbiology cultures, flow cytometry, molecular tests-cytogenetics etc.) is recommended as indicated.</li>
</ol>
Representative Results:
<img border="0" src="/files/ftp_upload/1404/1404fig1tmb.jpg" alt="Semi-ripped banana or sausage in experiment setup with silicone caulk and plastic wrap on support." data-altupdatedat="1747911167000" data-alt="figure 1"> <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/1404/1404fig1.jpg">Please click here to see a larger version of figure 1</a>.
 
Figure 1. Material required for preparing AV Phantom for practicing FNA proficiency (*We use Saran plastic wrap which did not stick to the caulk at the end, while removing after complete curing of the caulk.)
<hr style="border-bottom:1px dotted #999999;">

<img border="0" src="/files/ftp_upload/1404/1404fig2tmb.jpg" alt="Caulk application diagram; steps for creating a phantom lesion for FNA procedure simulation." data-altupdatedat="1747911167000" data-alt="figure 2"> 
<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/1404/1404fig2.jpg">Please click here to see a larger version of figure 2.</a>
 
Figure 2. Preparing AV Phantom lesion
<hr style="border-bottom:1px dotted #999999;">

<img border="0" src="/files/ftp_upload/1404/1404fig3tmb.jpg" alt="FNA biopsy process diagram with needle insertion, vacuum application, and pressure equalization." data-altupdatedat="1747911167000" data-alt="figure 3"> 
<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/1404/1404fig3.jpg">Please click here to see a larger version of figure 3.</a>
 
Figure 3. Critical steps in FNA procedure.
<hr style="border-bottom:1px dotted #999999;">

<img border="0" src="/files/ftp_upload/1404/1404fig4tmb.jpg" alt="Syringe pressure equilibration diagram; steps for valve operation and vacuum creation in experiments." data-altupdatedat="1747911167000" data-alt="figure 4"> 
<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/1404/1404fig4.jpg">Please click here to see a larger version of figure 4.</a>
 
Figure 4. EUS-FNA- Summary of Critical steps* (see Fig 3)
<hr style="border-bottom:1px dotted #999999;">

<img border="0" src="/files/ftp_upload/1404/1404fig5tmb.jpg" alt="Lesion aspirate sampling diagram; steps A-E; errors like capillary action, pressure imbalance noted." data-altupdatedat="1747911167000" data-alt="figure 5"> 
<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/1404/1404fig5.jpg">Please click here to see a larger version of figure 5.</a>
 
Figure 5. Pitfalls related to the critical steps in FNA procedure.
<hr style="border-bottom:1px dotted #999999;">

<img border="0" src="/files/ftp_upload/1404/1404fig6tmb.jpg" alt="Cytopathology smear techniques diagram; slide preparation methods: spreading, ribbing, film-making." data-altupdatedat="1747911167000" data-alt="figure 6"> 
<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/1404/1404fig6.jpg">Please click here to see a larger version of figure 6.</a>
 
Figure 6. Preparation of direct smears of FNA specimen between two slides.
<hr style="border-bottom:1px dotted #999999;">

<img border="0" src="/files/ftp_upload/1404/1404fig7tmb.jpg" alt="Pap smear comparison, wet-fixed vs air-dried, microscopic image, cellular detail study, diagnostic analysis." data-altupdatedat="1747911167000" data-alt="figure 7"> 
<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/1404/1404fig7.jpg">Please click here to see a larger version of figure 7.</a>
 
Figure 7. Wet fixed versus Air-dried smears.
<hr style="border-bottom:1px dotted #999999;">

<img border="0" src="/files/ftp_upload/1404/1404fig8tmb.jpg" alt="Pap stain comparison: Diagram of air-dried vs. wet-fixed smears; cell nuclei clarity in cytology." data-altupdatedat="1747911167000" data-alt="figure 8"> 
<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/1404/1404fig8.jpg">Please click here to see a larger version of figure 8.</a>
 Figure 8.Wet fixed versus Air-dried smears.

<ol>
	<li>Shidham, V. B., Pandit, A. W., Rao, R. N., Basir, Z., Shidham, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Tissue+Harvester+with+Functional+Valve+(THFV):+Shidham's+device+for+reproducibly+higher+specimen+yield+by+fine+needle+aspiration+biopsy+with+easy+to+perform+steps.">Tissue Harvester with Functional Valve (THFV): Shidham's device for reproducibly higher specimen yield by fine needle aspiration biopsy with easy to perform steps.</a> BMC Clinical Pathology. 7 (2), (2007).</li><li>Shidham, V. B., Epple, J., Shidham, V. B., Atkinson, B. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=AppendiX+I:+Collection+and+processing+of+effusion+fluids+for+cytopathologic+evaluation.">AppendiX I: Collection and processing of effusion fluids for cytopathologic evaluation.</a> , 207-235 (2007).</li><li>Shidham, V., Kampalath, B., England, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Routine+air+drying+of+all+the+smears+prepared+during+fine+needle+aspiration+and+intraoperative+cytology+studies:+An+opportunity+to+practice+a+unified+protocol,+offering+the+flexibility+of+choosing+variety+of+staining+methods.">Routine air drying of all the smears prepared during fine needle aspiration and intraoperative cytology studies: An opportunity to practice a unified protocol, offering the flexibility of choosing variety of staining methods.</a> Acta Cytologica. (45), 60-68 (2001).</li></ol>

Fine-needle aspiration biopsies (FNAB) are widely performed as an economical, safe, and rapid minimally invasive technique for tissue diagnosis of various tumors and lesions. In this procedure a 18 to 27 gauge needle is inserted into the lesion, moved back and forth multiple times in different areas of the lesion under controlled vacuum (suction) of variable intensity ranging from minimal in the form of only capillary action to about 10 ml vacuum in syringe to retrieve diagnostic tissue material. A finer gauge needle with higher number is preferred to retrieve good cytology material to prepare direct smears. Wider gauge needle of 18G retrieves more sample suitable for cell block, flow cytometry, electron microscopy, cytogenetics, microbiology cultures etc. Although the procedure is simple, controlling various steps with proper application and release of vacuum at appropriate steps in concerted manner is extremely crucial for optimum results. 
Due to non-availability of specially designed high-yield needles, conventional hypodermic needles or their modifications are used to perform this procedure. However, the hypodermic needles have many limitations leading to a low yield of specimen if used in conventional manner. The requirement of special syringe grips usually adds to the complexity of the procedure. Thus, due to the lack of commercially available suitable FNAB needle device, this highly versatile procedure suffers a frequent problem of inadequate specimen retrieval. Recently, a device increasing the yield with reproducibility has been reported [1].
In addition, currently there is a lack of suitable model for practicing proficiency in performing FNAB by health personnel in training including residents and fellows. We had standardized a model with a piece of fresh cattle liver stuffed in latex glove for practicing FNAB proficiency. However, this model is difficult to organize at a short notice. Procurement of fresh cattle liver is usually the limiting predicament. In addition, handling of liver may introduce contamination-related factors as a significant draw back. The tendency for the latex glove to leak after a few needle pricks leads to potential mess during the practice session.
We report and describe a novel but simple method of embedding a small piece of banana (or sausage) in a commercially available silicone rubber caulk and other easily available material. The FNAB phantom retains vacuum seal thus permitting aspiration of material from the embedded specimen, equivalent to the actual FNAB procedure on a lesion in clinical setting. In this video, we demonstrate the procedure of making FNAB phantom lesion and practicing FNAB procedure. It also demonstrates in brief the processing of retrieved specimen including smear preparation and staining [2,3]. 
Because the caulk takes time to cure, the phantom lesion should be prepared in advance about 24 to 48 hours prior to the practicing session. Comparable ready to use phantom lesion may be obtained from a commercial source (FNA Source, USA).
The phantom lesion for practicing FNAB proficiency may be used for training the residents and fellows prior to the beginning of FNAB performance on patients in the clinical setting.

preparation and using phantom lesions to practice fine needle aspiration biopsies

Currently, health workers including residents and fellows do not have a suitable phantom model to practice the fine- needle aspiration biopsy (FNAB) procedure. In the past, we standardized a model consisting of latex glove containing fresh cattle liver for practicing FNAB. However, this model is difficult to organize and prepare on short notice, with the procurement of fresh cattle liver being the most challenging aspect. Handling of liver with contamination-related problems is also a significant draw back. In addition, the glove material leaks after a few needle passes, with resulting mess.
We have established a novel simple method of embedding a small piece of sausage or banana in a commercially available silicone rubber caulk. This model allows the retention of vacuum seal and aspiration of material from the embedded specimen, resembling an actual FNAB procedure on clinical mass lesions.
The aspirated material in the needle hub can be processed similar to the specimens procured during an actual FNAB procedure, facilitating additional proficiency in smear preparation and staining.

Watch this Scientific Journal Video about Preparation and Using Phantom Lesions to Practice Fine Needle Aspiration Biopsies at JoVE.com

Preparation and Using Phantom Lesions to Practice Fine Needle Aspiration Biopsies

Practicing of fine needle aspiration biopsies (FNAB) by trainees is relatively challenging, due to the lack of an easily available, appropriate lesion. Preparation of an AV phantom lesion for practicing the FNAB procedure and mastering proficiency is relatively easy.

Currently, health workers including residents and fellows do not have a suitable phantom model to practice the fine- needle aspiration biopsy (FNAB) ...

preparation-using-phantom-lesions-to-practice-fine-needle-aspiration

Nanyang Technological University

Research

JoVE Journal

Biology

17.9K Views.  University of Wisconsin - Milwaukee. Het beoefenen van de fijne naald aspiratie biopsie (FNAB) door stagiairs is relatief uitdagend, vanwege het ontbreken van een gemakkelijk beschikbaar, passend laesie. De voorbereiding van een AV-fantoom laesie voor de uitoefening van FNAB procedure en de mastering vaardigheid is relatief eenvoudig.

Video: Preparation and Using Phantom Lesions to Practice Fine Needle Aspiration Biopsies

Performing and Processing FNA of Anterior Fat Pad for Amyloid

Historically, heart, liver, and kidney biopsies were performed to demonstrate amyloid deposits in amyloidosis. Since the clinical presentation of this disease is so variable and non-specific, the associated risks of these biopsies are too great for the diagnostic yield. Other sites that have a lower biopsy risk, such as skin or gingival, are also relatively invasive and expensive. In addition, these biopsies may not always have sufficient amyloid deposits to establish a diagnosis. Fat pad aspiration has demonstrated good clinical correlation with low cost and minimal morbidity. However, there are no standardized protocols for performing this procedure or processing the aspirated specimen, which leads to variable and nonreproducible results. The most frequently utilized modality for detecting amyloid in tissue is an apple-green birefringence on Congo red stained sections using a polarizing microscope. This technique requires cell block preparation of aspirated material. Unfortunately, patients presenting in early stage of amyloidosis have minimal amounts of amyloid which greatly reduces the sensitivity of Congo red stained cell block sections of fat pad aspirates. Therefore, ultrastructural evaluation of fat pad aspirates by electron microscopy should be utilized, given its increased sensitivity for amyloid detection. This article demonstrates a simple and reproducible procedure for performing anterior fat pad aspiration for the detection of amyloid utilizing both Congo red staining of cell block sections and electron microscopy for ultrastructural identification.

Fat pad aspiration is a preferred, minimally invasive, and low cost approach as compared to other methods to detect amyloid for diagnosis of systemic amyloidosis. This video article demonstrates a procedural outline for performing fat pad aspiration with appropriate processing of the specimen for the optimal diagnostic outcome.

Historically, heart, liver, and kidney biopsies were performed to demonstrate amyloid deposits in amyloidosis.  Since the clinical presentation of this ...

Medicine

Construction of a Preclinical Multimodality Phantom Using Tissue-mimicking Materials for Quality Assurance in Tumor Size Measurement

World Health Organization (WHO) and the Response Evaluation Criteria in Solid Tumors (RECIST) working groups advocated standardized criteria for radiologic assessment of solid tumors in response to anti-tumor drug therapy in the 1980s and 1990s, respectively. WHO criteria measure solid tumors in two-dimensions, whereas RECIST measurements use only one-dimension which is considered to be more reproducible 1, 2, 3,4,5. These criteria have been widely used as the only imaging biomarker approved by the United States Food and Drug Administration (FDA) 6. In order to measure tumor response to anti-tumor drugs on images with accuracy, therefore, a robust quality assurance (QA) procedures and corresponding QA phantom are needed.
To address this need, the authors constructed a preclinical multimodality (for ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI)) phantom using tissue-mimicking (TM) materials based on the limited number of target lesions required by RECIST by revising a Gammex US commercial phantom 7. The Appendix in Lee et al. demonstrates the procedures of phantom fabrication 7. In this article, all protocols are introduced in a step-by-step fashion beginning with procedures for preparing the silicone molds for casting tumor-simulating test objects in the phantom, followed by preparation of TM materials for multimodality imaging, and finally construction of the preclinical multimodality QA phantom. The primary purpose of this paper is to provide the protocols to allow anyone interested in independently constructing a phantom for their own projects. QA procedures for tumor size measurement, and RECIST, WHO and volume measurement results of test objects made at multiple institutions using this QA phantom are shown in detail in Lee et al. 8.

This paper describes in-house procedures of constructing a preclinical multimodality phantom made of tissue-mimicking (TM) materials for quality assurance (QA) of tumor size measurement in animal imaging modalities such as ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI).

World Health Organization (WHO) and the Response Evaluation Criteria in Solid Tumors (RECIST) working groups advocated standardized criteria for ...

Bioengineering

A Melanoma Patient-Derived Xenograft Model

Accumulating evidence suggests that molecular and biological properties differ in melanoma cells grown in traditional two-dimensional tissue culture vessels versus in vivo in human patients. This is due to the bottleneck selection of clonal populations of melanoma cells that can robustly grow in vitro in the absence of physiological conditions. Further, responses to therapy in two-dimensional tissue cultures overall do not faithfully reflect responses to therapy in melanoma patients, with the majority of clinical trials failing to show the efficacy of therapeutic combinations shown to be effective in vitro. Although xenografting of melanoma cells into mice provides the physiological in vivo context absent from two-dimensional tissue culture assays, the melanoma cells used for engraftment have already undergone bottleneck selection for cells that could grow under two-dimensional conditions when the cell line was established. The irreversible alterations that occur as a consequence of the bottleneck include changes in growth and invasion properties, as well as the loss of specific subpopulations. Therefore, models that better recapitulate the human condition in vivo may better predict therapeutic strategies that effectively increase the overall survival of patients with metastatic melanoma. The patient-derived xenograft (PDX) technique involves the direct implantation of tumor cells from the human patient to a mouse recipient. In this manner, tumor cells are consistently grown under physiological stresses in vivo and never undergo the two-dimensional bottleneck, which preserves the molecular and biological properties present when the tumor was in the human patient. Notable, PDX models derived from organ sites of metastases (i.e., brain) display similar metastatic capacity, while PDX models derived from therapy naive patients and patients with acquired resistance to therapy (i.e., BRAF/MEK inhibitor therapy) display similar sensitivity to therapy.

Patient-derived xenograft (PDX) models more robustly recapitulate melanoma molecular and biological features and are more predictive of therapy response compared to traditional plastic tissue culture-based assays. Here we describe our standard operating protocol for the establishment of new PDX models and the characterization/experimentation of existing PDX models.

Accumulating evidence suggests that molecular and biological properties differ in melanoma cells grown in traditional two-dimensional tissue culture ...

Cancer Research

Tissue-simulating Phantoms for Assessing Potential Near-infrared Fluorescence Imaging Applications in Breast Cancer Surgery

Inaccuracies in intraoperative tumor localization and evaluation of surgical margin status result in suboptimal outcome of breast-conserving surgery (BCS). Optical imaging, in particular near-infrared fluorescence (NIRF) imaging, might reduce the frequency of positive surgical margins following BCS by providing the surgeon with a tool for pre- and intraoperative tumor localization in real-time. In the current study, the potential of NIRF-guided BCS is evaluated using tissue-simulating breast phantoms for reasons of standardization and training purposes.
Breast phantoms with optical characteristics comparable to those of normal breast tissue were used to simulate breast conserving surgery. Tumor-simulating inclusions containing the fluorescent dye indocyanine green (ICG) were incorporated in the phantoms at predefined locations and imaged for pre- and intraoperative tumor localization, real-time NIRF-guided tumor resection, NIRF-guided evaluation on the extent of surgery, and postoperative assessment of surgical margins. A customized NIRF camera was used as a clinical prototype for imaging purposes.
Breast phantoms containing tumor-simulating inclusions offer a simple, inexpensive, and versatile tool to simulate and evaluate intraoperative tumor imaging. The gelatinous phantoms have elastic properties similar to human tissue and can be cut using conventional surgical instruments. Moreover, the phantoms contain hemoglobin and intralipid for mimicking absorption and scattering of photons, respectively, creating uniform optical properties similar to human breast tissue. The main drawback of NIRF imaging is the limited penetration depth of photons when propagating through tissue, which hinders (noninvasive) imaging of deep-seated tumors with epi-illumination strategies.

Near-infrared fluorescence (NIRF) imaging may improve therapeutic outcome of breast cancer surgery by enabling intraoperative tumor localization and evaluation of surgical margin status. Using tissue-simulating breast phantoms containing fluorescent tumor-simulating inclusions, potential clinical applications of NIRF imaging in breast cancer patients can be assessed for standardization and training purposes.

Inaccuracies in intraoperative tumor localization and evaluation of surgical margin status result in suboptimal outcome of breast-conserving surgery ...

Use of Electromagnetic Navigational Transthoracic Needle Aspiration (E-TTNA) for Sampling of Lung Nodules

Lung nodule evaluation represents a clinical challenge especially in patients with intermediate risk for malignancy. Multiple technologies are presently available to sample nodules for pathological diagnosis. Those technologies can be divided into bronchoscopic and non-bronchoscopic interventions. Electromagnetic navigational bronchoscopy is being extensively used for the endobronchial approach to peripheral lung nodules but has been hindered by anatomic challenges resulting in a 70% diagnostic yield. Electromagnetic navigational guided transthoracic needle lung biopsy is novel non-bronchoscopic method that uses a percutaneous electromagnetic tip tracked needle to obtain core biopsy specimens. Electromagnetic navigational transthoracic needle aspiration complements bronchoscopic techniques potentially allowing the provider to maximize the diagnostic yield during one single procedure. This article describes a novel integrated diagnostic approach to pulmonary lung nodules. We propose the use of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging; radial EBUS, navigational bronchoscopy and E-TTNA during one single procedure to maximize diagnostic yield and minimize the number of invasive procedures needed to obtain a diagnosis. This manuscript describes in detail how the navigation transthoracic procedure is performed. Additional clinical studies are needed to determine the clinical utility of this novel technology.

Use of Electromagnetic Navigational Transthoracic Needle Aspiration E-TTNA for Sampling of Lung Nodules

We describe the novel use of electromagnetic navigational guided transthoracic needle aspiration for the pathologic assessment of human lung nodules.

Lung nodule evaluation represents a clinical challenge especially in patients with intermediate risk for malignancy. Multiple technologies are presently ...

Hand-held Clinical Photoacoustic Imaging System for Real-time Non-invasive Small Animal Imaging

Translation of photoacoustic imaging into the clinic is a major challenge. Handheld real-time clinical photoacoustic imaging systems are very rare. Here, we report a combined photoacoustic and clinical ultrasound imaging system by integrating an ultrasound probe with light delivery for small animal imaging. We demonstrate this by showing sentinel lymph node imaging in small animals along with minimally invasive real-time needle guidance. A clinical ultrasound platform with access to raw channel data allows the integration of photoacoustic imaging leading to a handheld real-time clinical photoacoustic imaging system. Methylene blue was used for sentinel lymph node imaging at 675 nm wavelength. Additionally, needle guidance with dual modal ultrasound and photoacoustic imaging was shown using the imaging system. Depth imaging of up to 1.5 cm was demonstrated with a 10 Hz laser at a photoacoustic imaging frame rate of 5 frames per second.

A clinical handheld photoacoustic imaging system will be demonstrated for real-time non-invasive small animal imaging.

Translation of photoacoustic imaging into the clinic is a major challenge. Handheld real-time clinical photoacoustic imaging systems are very rare. Here, ...

Detection of Extravascular Trypanosoma Parasites by Fine Needle Aspiration

Fine Needle Aspiration (FNA) is a routine diagnostic procedure essential to both medical and veterinary practices. It consists of the percutaneous aspiration of cells and/or microorganisms from palpable masses, organs or effusions (fluid accumulation in a body cavity) using a thin needle similar to the regular needle used for the venous puncture. The material collected by FNA is in general highly cellular, and the retrieved aspirate is then smeared, air dried, wet-fixed, stained and observed under a microscope. In the clinical context, FNA is an important diagnostic tool that serves as a guide to the appropriate therapeutic management. Because it is simple, fast, minimally invasive and requires limited investment in the laboratory and human resources, it is extensively used by veterinary practitioners, mostly in domestic, but also in farm animals. In studies using animal models, FNA has the advantage that it can be performed repeatedly in the same animal, enabling longitudinal studies through the collection of cells from tumors and organs/tissues over the course of the disease. In addition to routine microscopy, retrieved material can also be used for immunocytochemistry, electron microscopy, biochemical analysis, flow cytometry, molecular biology or in vitro assays. FNA has been used to identify the protozoan parasite Trypanosoma brucei in the gonads of infected mice, opening the possibility for a future diagnosis in cattle.

Detection of Extravascular Trypanosoma Parasites by Fine Needle Aspiration

Fine Needle Aspiration is a technique, whereby cells are obtained from a lesion or organ using a thin needle. Aspirated material is smeared, stained and examined under a microscope for diagnosis or used for molecular biology, cytometry or in vitro analysis. It is cheap, simple, quick and causes minimal trauma.

Fine Needle Aspiration (FNA) is a routine diagnostic procedure essential to both medical and veterinary practices. It consists of the percutaneous ...

Immunology and Infection

Micro-Ultrasound Guided Transperineal Prostate Biopsy: A Clinic-Based Procedure

Prostate cancer is the most common solid malignancy in men and requires a biopsy for diagnosis. This manuscript describes a freehand micro-ultrasound guided transperineal technique performed under local anesthesia, which maintains accuracy, keeps patients comfortable, has low adverse events, and minimizes the need for disposables. Prior micro-ultrasound-guided transperineal techniques required general or spinal anesthesia. The key steps described in the protocol include (1) the placement of the local anesthesia, (2) micro-ultrasound imaging, (3) and the visualization of the anesthetic/biopsy needle while uncoupled from the insonation plane. A retrospective review of 100 patients undergoing this technique demonstrated a 68% clinically significant cancer detection rate. Pain scores were prospectively collected in a subset of patients (N = 20) and showed a median procedural pain score of 2 out of 10. The 30 day Grade III adverse event rate was 3%; one of these events was probably related to the prostate biopsy. Overall, we present a simple, accurate, and safe technique for performing a micro-ultrasound-guided transperineal prostate biopsy.

This manuscript outlines the steps for performing a micro-ultrasound-guided transperineal prostate biopsy under local anesthesia.

Prostate cancer is the most common solid malignancy in men and requires a biopsy for diagnosis. This manuscript describes a freehand micro-ultrasound ...

A Stepwise Approach for Performing Ultrasound Guided Transthoracic Lung Biopsy

Diagnosing patients with radiological lung lesions, especially those suspected of having primary lung cancer, is a common and critical clinical scenario. When selecting the most suitable invasive procedure to establish a diagnosis in these cases, a delicate balance must be struck between achieving a high diagnostic yield, providing staging information, minimizing potential complications, enhancing the patient experience, and controlling costs. The integration of thoracic ultrasound as a routine clinical tool in respiratory medicine has led to increased awareness and utilization of ultrasound-guided invasive techniques in chest procedures, including transthoracic biopsies. By following a systematic and stepwise approach, transthoracic ultrasound-guided lung biopsy emerges as a safe, cost-effective procedure with a remarkable diagnostic accuracy. These attributes collectively position it as an ideal invasive technique when technically feasible. Consequently, in patients presenting subpleural lung lesions suspected of malignancy, transthoracic ultrasound-guided lung biopsy has become a standard procedure in the realm of modern invasive pulmonology.

Transthoracic ultrasound-guided lung biopsy represents a safe, cost-effective, and efficient approach for patients presenting with subpleural lung lesions suspected of malignancy. Employing a systematic, step-by-step process is crucial to achieve optimal patient selection, minimize complication risks, and maximize diagnostic accuracy.

Diagnosing patients with radiological lung lesions, especially those suspected of having primary lung cancer, is a common and critical clinical scenario. ...

Building Custom Ballistic Gel Ultrasound Phantoms for Nerve Block Simulations

Building Affordable, Durable, Medium-Fidelity Ballistic Gel Phantoms for Ultrasound-Guided Nerve Block Training

Ultrasound phantoms - alternatives to live human tissue - give learners the opportunity to practice ultrasound-guided regional anesthesia without introducing undue risk to patients. Gelatin-based phantoms provide educators with durable and reusable task trainers; however, commercially available gel-based phantoms are expensive. Here, we investigate the production of durable, low-cost, ballistic gel-based ultrasound phantoms for median, femoral, suprainguinal fascia iliaca plane, and serratus anterior plane nerve blocks, as well as a methodology for producing a phantom for any ultrasound-guided nerve block procedure.
Computer-aided design (CAD) software was utilized to design four phantoms replicating the anatomy of median, femoral, suprainguinal fascia iliaca plane, and serratus anterior plane nerve blocks, including relevant landmarks and tissue planes. Plastic models of the desired tissue planes were 3D printed and used to create silicone molds. Ballistic gel was melted and mixed with flour and dye to create a liquid, echogenic ballistic gel, which was poured into the silicone molds. Vessels were simulated by creating negative space in the ballistic gel using metal rods. Nerves were simulated using yarn submerged in ultrasound gel. Simulated bones were designed using CAD and 3D printed.
Ballistic gel is a versatile, durable medium that can be used to simulate a variety of tissues and can be melted and molded into any shape. Under ultrasound, these phantoms provide realistic tissue planes that represent the borders between different layers of skin, muscle, and fascia. The echogenicity of the muscle tissue layers, nerves, vessels, and bones is realistic, and bones have significant posterior shadowing as would be observed in a human subject. These phantoms cost $200 each for the first phantom and $60 for each subsequent phantom. These phantoms require some technical skill to design, but they can be built for just 4% of the cost of their commercial counterparts.

Author Spotlight: Developing Cost-Effective and Durable Ultrasound-Guided 3D-Printed Nerve Block Trainers

Here, we demonstrate the design and creation of four custom ballistic gelatin ultrasound phantoms for ultrasound-guided regional anesthesia training. We designed the phantoms using computer-aided design software, used 3D-printed models to create silicone molds, and then poured melted ballistic gel into the molds to create custom tissue layers.

Preparation and Using Phantom Lesions to Practice Fine Needle Aspiration Biopsies

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