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Palpation guided fine needle aspiration
Superficial FNA procedure: contraindications and complications


Joseph D. Jakowski, M.D.

Last author update: 1 August 2013
Last staff update: 21 September 2023 (update in progress)

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PubMed Search: Fine needle aspiration contraindications and complications


Joseph D. Jakowski, M.D.
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Table of Contents
Definition / general | Contraindications | Complications | Complications following thyroid FNA | Additional rare FNA complications to consider | Other considerations
Cite this page: Jakowski J. D. FNA contraindications and complications. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/cytopathologyfnacontraindications.html. Accessed November 29th, 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:
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)
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