Haemopneumothorax after fine needle aspiration of the breast

Fine needle aspiration (FNA) of the breast is commonly performed without image guidance. Complications are rare but can be serious.

CASE HISTORY

A woman of 54 was referred to the breast unit with a recurrent tender left upper outer quadrant mass. Mammography showed an asymmetrical density with no features of carcinoma. ‘Blind’ (non-image-guided) FNA yielded insufficient cells for diagnosis. Six weeks later she returned for a further blind FNA, subsequently reported as showing red blood cells and normal epithelial cells. 32 hours after the second FNA she was seen in the emergency department with left-sided pleuritic chest pain and dyspnoea. She was cyanosed, with a respiratory rate of 22 per minute and oxygen saturation 88% on air. Her trachea was deviated to the right. There was reduced expansion and air entry on the left, associated with ipsilateral chest wall tenderness. Pulse rate was 110 per minute and blood pressure 88/58 mmHg. Haemoglobin was 12.1 g/dL, coagulation normal; white cell count 16.1 × 10⁹/L; platelet count 382 × 10⁹/L.

Needle thoracocentesis in the second intercostal space yielded 800 mL of air. A chest X-ray subsequently showed a large left-sided haemothorax without residual pneumothorax. She remained breathless and a size 26 chest drain was inserted with immediate drainage of 1200 mL blood. Over the next 2 hours the chest drain produced a further 1200 mL. Despite 2 units of blood, 1 L colloid and 2 L crystalloid via a central line she remained hypotensive and the thoracic surgeons recommended urgent thoracotomy. At operation the source of bleeding was located at the apex of the lung. A vascular adhesion had become disrupted by the development of the pneumothorax that followed the FNA. Postoperatively she spent 4 days in intensive care, requiring a total of 14 units of blood and 8 units of fresh frozen plasma.

COMMENT

FNA is the fastest and easiest method of breast biopsy, and the results are rapidly available. Pneumothorax is a recognized complication, with an incidence ranging from 0.01% to 3%.² Risk factors are deep breast lumps, thin body build and breath-holding during the procedure. The complication has been associated with FNA in any of the four quadrants of the breast but especially with aspiration in the outer upper quadrant. In 50-80% of cases no specific treatment is needed; the remainder require insertion of a chest drain.^3,4 Haemopneumothorax following FNA of a breast lump has not to our knowledge been previously reported. In the present case the bleeding was life-threatening and required open thoracotomy, although thoracoscopy⁵ might have been an alternative.

The risk of pneumothorax can be lessened by technique: the patient should breathe normally⁴ and the needle should be inserted into the mass parallel rather than perpendicular to the chest wall whenever possible^2,3 especially in thin patients² with small breasts. In addition, blind aspiration is giving way to image-guided methods, the simplest of which is ultrasound.⁶ If the lesion is visible ultrasonically, the needle can be followed in real time to its destination. Other methods of image guidance are CT,^6,7 stereotactic mammography⁸ and MR.⁹ MR-guided biopsy is not yet widespread but is likely to be used increasingly by hospitals and diagnostic centres.