Architecture and cohesion
Unit 1 of 8
Read the low power pattern: cohesive fragments and flat sheets against crowded fragments and dispersed single cells.
At low power you are reading a pattern, not a cell. Benign aspirates hold together: large cohesive fragments and flat sheets, with the cells evenly spaced inside them. Malignant aspirates come apart: crowded fragments with overlapping nuclei, and single cells scattered across the glass.
Cohesion is the first thing a cytologist reads and the last thing a measurement can reach. The pipeline can count how many nuclei stand alone after a 2 micron dilation, which is a proxy for dispersal, and it can count how many lie in a fragment of six or more. It cannot see a flat sheet as a sheet.
So read the two patches below the way you would read them down a microscope at low power, then check the two counts under each.
The criteria, quoted
C2 Benign
A benign breast FNAB diagnosis is made in cases that have unequivocally benign cytological features, which may or may not be diagnostic of a specific benign lesion.
- Risk of malignancy
- 1.4 to 2.3 percent
- Management
If the triple test is benign, no further biopsy is required; if clinical or imaging findings are suspicious, repeat FNAB or proceed to CNB.
A cytologist would look for
predominantly large cohesive three-dimensional tissue fragments and flat mono-layered sheets
evenly spaced ductal epithelial cells with myoepithelial cells creating a bimodal pattern
bare bipolar nuclei representing stripped myoepithelial nuclei, in the background
C5 Malignant
An unequivocal statement that the material is malignant, and the type of malignancy identified should be stated whenever possible.
- Risk of malignancy
- 99 to 100 percent
- Management
If the triple test is concordant, proceed to definitive management; if discrepant, CNB or excision biopsy is mandatory.
A cytologist would look for
high cellularity, prominent dispersal of single cells
crowded tissue fragments with overlapping nuclei
nuclear enlargement, anisonucleosis, pleomorphism of the nuclear margin, size and chromatin, hyperchromasia and prominent nucleoli
a greatly reduced number or total lack of myoepithelial cells associated with the epithelial tissue fragments, and scant or absent bare bipolar nuclei
The worked example
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About 20 trials, 5 to 8 minutes. You can stop at any point.