Table of Contents
Definition / general | Contraindications | Complications | Complications following thyroid FNA | Additional rare FNA complications to consider | Other considerationsCite this page: Jakowski J. D. FNA contraindications and complications. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/cytopathologyfnacontraindications.html. Accessed June 5th, 2023.
Definition / general
- Aspirator: be aware of possible contraindications and complications of FNA and inform the patient
- Always weigh risk to benefit ratio on an individual basis before the FNA procedure
Contraindications
- For superficial FNA, most contraindications are relative rather than absolute
- FNA may be preferable in at risk patients with significant comorbidities who cannot tolerate a more invasive procedure (surgery) for diagnosis
- Possible contraindications for superficial FNA biopsy include:
- Uncooperative or excessively apprehensive patient
- For thyroid, those who cannot suppress their cough reflex: at risk for thyroid laceration by needle
- Certain tumors and tumor like conditions:
- Pargangliomas (including carotid body tumors): possible risk of syncope, acute hypertension, hemorrhage
- Echinococcal cyst and suspected hydatid disease: rare risk of anaphylaxis including fatal reactions and cyst rupture
- Highly vascular lesions (i.e. vascular malformation): at risk for hemorrhage and non diagnostic FNA
- Controversial and not currently supported:
- FNA of testicular malignancies: theoretical, but not proven, risk of tumor implantation
- Factors that put the patient at risk for complications during or after the superficial FNA biopsy:
- Bleeding disorders or anticoagulant therapy (e.g. aspirin, Coumadin, Plavix): especially for head and neck FNA (e.g. thyroid), where possible bleeding / hematoma formation has the potential for mass effect leading to airway compromise
- Diagn Cytopathol 1997;17:239, Demay: The Art & Science of Cytopathology, 2nd Edition, 2011 (vol. 2, pg. 543)
Complications
- Superficial FNA is a BIOPSY and has possible complications, albeit rare, that are almost always minor
- The overwhelming volume of literature supports the safety of FNA
- Superficial FNA (i.e. targets that are above the fascia) have a lower complication rate than FNA of deep seated organs (e.g. liver, lung, kidney)
- Complications rise exponentially with increasing needle size and FINE needles (22 gauge needle or smaller diameter needle) have the lowest complication rates
- Generally, the more experienced the aspirator, the fewer the complications
- The most commonly encountered complications for superficial FNA include:
- Minor pain / discomfort (increases with needle size)
- Bleeding (ecchymosis / hematoma)
- Rarely vasovagal reaction (lightheadedness / fainting) or infection (Demay: The Art & Science of Cytopathology, 2nd Edition, 2011 (vol. 2, pg. 540-1))
Complications following thyroid FNA
- Summary of possible clinical complications following thyroid FNA from 20,000 FNA patients (Clin Endocrinol 2009;71:157), given with likelihood in percentages or as the number of case reports:
- Pain / discomfort (up to 92%) (minor, transient and well tolerated)
- Hemorrhage / hematoma:
- Small hematomas (0.3 - 26%)
- Massive hematomas (rare, 5 - 10 reported cases)
- Neuritis following hematoma (extremely rare, < 5 reported cases)
- Pseudoaneurysm (extremely rare, < 5 reported cases)
- Carotid hematoma (extremely rare, < 5 reported cases)
- Secondary hemangioma (extremely rare, < 5 reported cases)
- Acute transient swelling (extremely rare, < 5 reported cases)
- Delayed transient swelling (extremely rare, < 5 reported cases)
- Infection (rare, 5 - 10 reported cases)
- Recurrent laryngeal nerve palsy (0.036 - 0.9%)
- Vasovagal reaction (0.5 - 1.3%)
- Tracheal puncture (0.3%)
- Dysphagia (extremely rare, < 5 reported cases)
- Needle track seeding:
- Papillary thyroid carcinoma (0.14%)
- Other thyroid carcinomas (extremely rare, < 5 reported cases)
- Nodule volume alterations (13 - 35%) (e.g. nodule volume change > 50% over baseline)
- Post aspiration thyrotoxicosis (1%)
Additional rare FNA complications to consider
- Pneumothorax:
- Rare known complication resulting from superficial FNA of a target on or near the chest, including breast, supraclavicular area and axilla, especially in thin patients
- May be more common complication in the hands of trainees (Br J Surg 2002;89:134)
- Estimated at 0.01 - 0.18% (although as high as 1 in 417 has been reported)
- Techniques that may help decrease this complication include:
- Maintain the aspirating needle parallel or tangential to the chest wall
- Pulling a mobile lump away from the chest wall for the FNA
- Performing the aspiration in area of the lump which overlays a rib to further decrease the chance of pleural penetration
-
Post FNA infarction of the target and additional biopsy tissue alterations:
- Can occur with any biopsy method
- The smaller the needle, the less likely the tissue alterations will occur
- Rare event with most reported cases occurring after FNA biopsy of a neoplasm
- Partial or total infarction may cause varying degrees of difficulty in histologic examination of surgical specimen and confirmation of cytologic diagnosis
- Infarctions / necrosis may be more common in Hürthle cell tumors but both benign and malignant tumors may undergo these changes (Acta Cytol 1991;35:427, Diagn Cytopathol 1996;15:211)
- Surgical pathologist should be told that prior fine needle biopsy was performed and given the cytologic diagnosis
- Additional FNA biopsy tissue alterations that may be seen:
- Hemorrhage / hemosiderin laden macrophages
- Granulation tissue and benign spindle cell and endothelial proliferations
- Fibrosis
- Displaced non neoplastic epithelium
- May simulate malignancy
- Seen within FNA needle tract or perineural location
- Fat necrosis
-
Needle track seeding by tumor:
- Attracts much attention in medical literature and may be major concern to some patients (Diagn Cytopathol 1997;17:239, Demay: The Art & Science of Cytopathology, 2nd Edition, 2011 (vol. 2, pg. 543))
- Should not be a deterrent to FNA when indications are appropriate
- Is extremely rare using FINE needles as defined above when compared with large bore needle biopsies (e.g. larger diameter needle than 22 gauge) or open / incisional surgical biopsies
- Estimated frequency of 0.003 - 0.009% for all FNA sites using FINE needles
- Most case reports of needle tract seeding occur with malignant tumors that are aggressive or present at high stage at diagnosis
- Conflicting reports on whether needle tract seeding by malignant tumors is unfavorable prognostic sign
- Early detection is probably important - effective treatment includes surgical removal, ablation, radiation
- Very rare needle tract seeding by benign tumors, tumor like conditions and even normal tissue has been reported:
- Parathyroid tissue
- Parathyroid adenoma
- Endometriosis
- Pleomorphic adenoma
- Colorectal adenoma
- Breast papilloma
- Metanephric adenoma of kidney
- Thymoma
- Hemangioma
-
Fatalities:
- Fatalities have been reported with all types of biopsy methods and FNA biopsy has the best safety record (Diagn Cytopathol 1997;17:239)
- Death from superficial FNA are almost nonexistent
- Single case reports of death from aspiration following a carotid body tumor and a fatal case of cervical edema following FNA have occurred
- Mortality rate for FNA of deep seated organs (e.g. liver, kidney, lung) has been reported up to 0.031%
Other considerations
- Other pre procedural patient factors / medical conditions to consider and prepare for that may rarely arise as a medical emergency during any office or hospital visit:
- Diabetes: hypoglycemic episode
- Seizures
- Anaphylaxis: to latex gloves or local anesthetic
- Heart conditions: angina and cardiac arrest
- Asthma exacerbation
- Hyperventilation
- Psychiatric conditions: anxiety disorder, bipolar, psychosis
- Syncope (Am Fam Physician 2007;75:1679)