Thyroid Nodules and Cancer 101: What can go wrong with cutting needle biopsies?

Thyroid Nodules and Cancer 101: What can go wrong with cutting needle biopsies?

Thyroid Nodules and Cancer 101: What can go wrong with cutting needle biopsies?

Thyroid Nodules and Cancer 101: What can go wrong with cutting needle biopsies CNB?

Core Needle Biopsy of the Thyroid: 2016 Consensus
Statement and Recommendations from Korean Society
of Thyroid Radiology Korean J Radiol 2017;18(1):217-237

Dong Gyu Na,et al

Complications
The guidelines, including those of the NCI and previous
studies, suggest that CNB is safe, well-tolerated, and
associated with a low incidence of complications when
performed by experienced operators (18, 21, 32). The
reported complication rate ranges from 0 to 4.1%, with
the major complication rate ranging from 0 to 1.9% (19,
45, 47, 50, 101). Because CNB is performed under realtime
US guidance, serious complications seem to be rare.
Nonetheless, various complications may occur, including
hematoma

3D image of a neck hematoma

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(18, 21, 22, 45, 101), hoarseness

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(19, 47),
infection (98, 101), hemoptysis (21), edema (15, 18, 22),
vasovagal reaction (101), and dysphagia

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(101). Besides
these complications, a recent large single-center study (6687
thyroid nodules of 6169 patients) found low rates of major
and minor complications (4/6169 [0.06%] and 49/6169
[0.79%], respectively) and no procedure-related death or
sequelae (102). To avoid complications, CNB should be
performed by an expert in the field of thyroid intervention
with continuous monitoring of the needle tip during the
procedure. Understanding of the neck anatomy, anatomic
variations, and potential complications is also required for
the safe performance of CNB (103).Pain and discomfort during or after CNB are a common
problem. However, CNB using 18–22-gauge cutting needles
with US guidance has allowed operators to decrease the
level of pain and frequency of complications (18). Two
recent studies compared the pain and tolerability of FNA
and CNB (104, 105) and concluded that the two procedures
are similar in terms of pain and tolerability.Vascular injury, resulting from needle-induced mechanical injury, is the most common complication after thyroid CNB.
Hematoma is the most common type of vascular injury,
although pseudoaneurysm and arteriovenous fistula have
been also reported after CNB and FNA (102, 106, 107). The
incidence of vascular injury has been reported to be up to
3.9% (102, 108), which is similar to that of FNA (1–6.4%)
(106). Edema can be associated with hematoma and pain
(15, 18, 22, 37). During the intervention of thyroid, various
types of hematomas can be detected in perithyroidal,
subcapsular, and intranodular locations (90) but are usually
successfully managed with simple compression of the neck
for between 30 and 120 minutes, with most hematomas
disappearing within 1 or 2 weeks (18, 22). Although most
hematomas are well controlled by manual compression, a
few cases of uncontrolled hemorrhage have been reported
after FNA that necessitated hospital admission and active
intervention due to acute upper airway obstruction (109-
111). For CNB, hemorrhage has been reported as a major
complication (45, 112). Therefore, in patients taking
drugs associated with a bleeding tendency, operators and
physicians should carefully consider the risk-benefit ratio
and withdraw those drugs before CNB. During the CNB,
perithyroidal vessels, including the superior and inferior
thyroid arteries, should be carefully evaluated using Doppler
US. The needle tip should not be advanced across the
thyroid capsule to prevent vascular injury (103).Manual
compression should be performed immediately after the
biopsy for 20 to 30 minutes after CNB. Patients should be
educated about the possibility of delayed hematoma and
how to manage the complication, although most hematomas
happen during or just after CNB (15, 18).
Voice change, caused by injury to the recurrent laryngeal
nerve, is a rare but serious complication after thyroid
CNB. A voice change incidence of up to 1.9% has been
reported in CNB (19), which is similar to that of FNA
(0.036–0.9%) (106). Quick stretching of the nerve over
the thyroid swelling and/or pressure on the nerve against
the trachea could be possible mechanisms of recurrent
laryngeal nerve palsy after CNB. Hemorrhage around the nerve

can also cause voice problems. Recurrent laryngeal
nerve palsy associated with hemorrhage is usually transient
and ameliorates after the hemorrhage is spontaneously
absorbed (113). Voice changes are usually transient but a
case of permanent injury has been reported in CNB because
of direct cutting of the recurrent laryngeal nerve through
a lateral approach method (97). A transisthmic approach
is recommended to prevent direct injury to the recurrent
laryngeal nerve. A safe distance from the needle tip should
be carefully measured before the stylet is fired and the
specimen notch should be monitored (103).
Thyroid infection and/or abscess formation have been
reported after CNB (98), but their incidence is very low due
to various protective mechanisms, including a rich blood
supply, rich lymphatic drainage, high content of iodine, and
the capsule surrounding the gland. Therefore, prophylactic
antibiotics are not recommended before or after CNB.
However, infection at the needle puncture site or direct
injury to the esophagus can cause infection (12). The
puncture site should be sterilized to prevent an infection,
and knowledge of US-based anatomy is necessary so as
not to misdiagnose the esophageal or pharyngoesophageal
diverticulum as a thyroid nodule (103, 114). In the case
of a mass located at the posteromedial margin of the
thyroid, CNB should be performed only after the operator
verifies that it is not a pharyngoesophageal or esophageal
diverticulum.
Cough and/or hemoptysis may be caused by direct injury
to the trachea by the core needle. Although puncture of
the trachea is a possible complication, there has been only
one case report of hemoptysis each after CNB (21) and FNA
(115). The hemoptysis spontaneously resolved and did not
require hospitalization.
Extrathyroidal tissue injury, including vessel, muscle,
or vertebral, may occur when the needle tip advances too
far across the thyroid capsule. Tinnitus has been reported,
caused by injury of the vertebral artery followed by an
arteriovenous fistula (107). A safe distance from the needle
tip should be carefully measured before the stylet is fired
so that it is not outside the thyroid capsule. Vasovagal
reaction and dysphagia are possible complications that can
improve with conservative treatments (101). Tumor seeding
after CNB of thyroid nodules has not been reported (116).
For safe and effective US-guided CNB, physicians should
understand the broad spectrum of complications as well
as how to prevent them. Knowledge of US-based thyroidal
and perithyroidal anatomy including vessels and nerves is required, as well as estimation of the risk-benefit ratio of
CNB, to prevent and minimize complications.
[Recommendation 11]
Core needle biopsy is safe, well-tolerated, and associated
with a low incidence of complications when performed by
experienced operators.

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