• Superficial FNA procedure is safe with relatively fewer major complications but there are a few limitations to this time and cost efficient procedure, which include the following
  • When there is a high degree of suspicion that cytology will not be sufficient to make the diagnosis and histology is needed (e.g., suspected lymphoma) (StatPearls: Fine Needle Aspiration [Accessed 1 September 2023])
  • Using breast FNA for primary diagnosis of breast lesions and prognostic / predictive biomarkers in breast carcinoma as it can be very challenging to interpret immunohistochemistry in breast pathology using FNA cell block material (Arch Pathol Lab Med 2021;145:825)
  • Distinguishing between in situ and invasive breast carcinoma using breast FNA (Diagn Cytopathol 2001;25:73)
  • Patients with severe coagulopathic disorders due to relative bleeding risks, which should be addressed carefully during the preprocedural decision making process (Endosc Int Open 2019;7:E15)
  • Risk of false negative result due to sampling error especially in thyroid and breast lesions (Thyroid 2004;14:207)
  • Risk of false positive results due to diagnostic misinterpretation especially in breast lesions; breast fine needle aspiration cytology (Cancer Cytopathol 2013;121:561)
  • Ethical dilemma regarding when to disclose the preliminary result to the patient as opposed to deferring the disclosure (AMA J Ethics 2016;18:779)

Parotid gland

• Parotitis
• Facial nerve paresis (Br J Oral Maxillofac Surg 2016;54:260)
• Seeding of malignant cells
  • Very rare complication due to displacement of tumor cells immediately after FNAC or core needle biopsy
  • It is not clear if disseminated malignant cells mature into tumor masses (along the needle track or in subcutaneous fat away from the tumor)
  • Histological features (associated with an inflammatory and multinucleated foreign body type giant cell response) have been suggested as diagnostic of seeding along the needle track (Br J Oral Maxillofac Surg 2016;54:260)
  • Lack of specific criteria for this entity and a defined interval after which the tumor developed make this complication clinically less relevant

Breast

• Bleeding
• Bruising
• Swelling at the aspirated site
• Pain
• Pneumothorax, in rare instances if the needle is advanced deep in the chest area, especially in patients with thin chest wall and chest wall deformities (Int Semin Surg Oncol 2005;2:14)
  • Pneumothorax is a relatively rare complication of breast FNA since the ribs form a much larger area of the chest wall surface than the intercostal muscles; furthermore, the pectoral muscles provide additional protective structures
  • Pneumothorax after breast FNA may be seen more frequently in patients who have thin body habitus and small sized breasts
  • Patients with deep central lesions or lesions in the tail of the breast are also at higher risk for developing this complication

Thyroid

• Bleeding
• Local pain at the aspirated site
• Cervical neuritis preceded by post-FNA hematoma
• Tumor seeding (Br J Oral Maxillofac Surg 2016;54:260)
• Acute or delayed transient swelling of the thyroid gland
• Recurrent laryngeal nerve injury
  • One of the infrequent complications
  • Incidence rate is still unknown
  • Multiple mechanisms have been proposed (nerve stretching by hematoma, inflammation, thrombosis in small arterioles and rarely direct injury to nerve) (Radiol Diagn Imaging 2017;1:1)
• Thyrotoxicosis (Clin Endocrinol (Oxf) 2009;71:157)
• Cutaneous sinus formation (Case Rep Endocrinol 2014;2014:923438)
• Very rarely, pseudoaneurysm in superior thyroid artery (Clin Endocrinol (Oxf) 2009;71:157)
• Very rarely, focal carotid intramural hematoma
• Acute bacterial thyroiditis
  • Rare complication representing only 0.7% of all thyroid FNA related complications
  • Can result in serious consequences (systemic sepsis, endangering the airways, cardiac arrhythmias)
  • Common bacteria involved are Staphylococcus aureus and Streptococcus sp. (Case Rep Endocrinol 2020:2020:7104806)

Which of the following is a contraindication for FNA?

1. Palpable cervical lymph node
2. Pulsatile neck lesions
3. Salivary gland mass or cyst
4. Superficial palpable skin and subcutaneous nodule

B. Pulsatile neck lesions. Pulsatile neck lesions are associated with higher risk of bleeding due to their vascular nature. The other options are incorrect as they are not contraindications for FNA. Answer C is incorrect because FNA is a helpful tool for differentiating neoplastic and nonneoplastic conditions and diagnosing most benign salivary gland neoplasms. Answer A is incorrect because FNA of palpable cervical lymph node is useful in the diagnosis of metastatic carcinomas and granulomatous processes. Answer D is incorrect because FNA is a reliable and useful procedure for the diagnosis of superficial palpable skin and subcutaneous nodules. Complications are quite rare, especially when using the small needle.

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Reference: Superficial FNA procedure: contraindications and complications

Which of the following statements regarding FNA is correct?

1. Complications are lower with superficial masses when compared to the deep seated masses
2. It cannot distinguish between in situ and invasive breast carcinoma
3. It cannot distinguish between neoplastic and nonneoplastic lesions
4. Patient understanding and consent are not necessary before the procedure

A. Complications are lower with superficial masses when compared to deep seated masses. Answer A is correct because complications, such as spread of infection or seeding of neoplastic cells through other tissue layers, are lower when FNA is performed on superficial masses as compared to the deep seated masses. Answer B is incorrect because FNA cannot reliably distinguish in situ from invasive carcinoma, as invasive features require documentation of stromal invasion in tissue biopsy. Answer C is incorrect because the FNA technique is very helpful in distinguishing between neoplastic and nonneoplastic lesions. Answer D is incorrect becausepatient understanding and consent are absolute requirements before performing the FNA.

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Reference: Superficial FNA procedure: contraindications and complications