in india , breast cancer is the second most common malignancy in females , next to cervical cancer 
 . the study by khanna et al . has shown increasing incidence 
 in breast cancer , especially in the younger age group . surgical 
 biopsy specimens serve as the  gold standard  for validating the diagnostic criteria 
 and the value of histological grading has been widely accepted . fine needle aspiration ( fna ) cytology is used for the preoperative diagnosis of breast 
 malignancies and its role in determining the prognosis is being studied by various authors . the 
 national cancer institute , bethesda , sponsored conference had also recommended that the tumour 
 grading on fna material should be incorporated in fna reports for prognostication . introduced the concept of nuclear grading , which was 
 modified and applied in cytological smears by fisher et al . numerous two - tier and three - tier systems have 
 been proposed for the cytological grading of breast tumors , but no single system is currently 
 adapted for use in the routine evaluation of cytological aspirates of breast carcinoma . in the present study , various three - tier cytological grading systems were studied and compared to 
 arrive at a simple , effective , reliable , and feasible system for the cytological grading of breast 
 carcinoma . this retrospective and prospective study was conducted in the department of pathology , sree 
 balaji medical college and hospital , chrompet , chennai , during the period of january 2012 to 
 december 2013 . a total of 157 fnac samples of breast tumors were received . out of which , 72 cases 
 had histopathological correlation and were included in the present study . the alcohol - fixed , 
 hematoxylin & eosin stained fnac smears were studied and graded independently by two 
 pathologists . the following 3-tier grading systems were assessed  fisher 's modification of 
 black 's nuclear grading , robinson 's method , dabbs and silverman cytological grading , and the grading 
 systems proposed by khan et al . , taniguchi et al . , mouriquand and d. pasquier , and howell et al . in fisher 's modification of black 's nuclear grading , ( figures 1 and 2 ) five 
 parameters  nuclear shape , chromatin , nucleoli , mitosis , and nuclear size , were graded i to 
 iii . in robinson 's grading system [ 7 , 8 ] , ( figures 3 , 4 , and 5 ) six parameters , 
 namely  cell dissociation , cell size , uniformity , nucleoli , nuclear margin , and chromatin , 
 were given a score of 13 . a total score in the range of 611 was graded as grade i , 
 1214 as grade ii , and 1518 as grade - iii . dabbs and silverman method   ( figure 6 ) employed grades from i to iii , depending upon the nuclear size and 
 shape , nuclear membrane , chromatin , and nucleoli . khan et al .   proposed a system , which included pleomorphism , nuclear size , nuclear margins , nucleoli , 
 naked tumor nuclei ( figure 7 ) , and mitotic count . the 
 parameters were scored from 1 to 3 and total scores in the range of 610 , 1114 , and 
 1518 were regarded as grade i , grade ii , and grade iii , respectively whereas taniguchi et 
 al .   included 7 parameters  necrosis ( absent - 
 score 0 , present - score 1 ) ( figure 8) , cellular size , 
 n  :  c ratio , nuclear pleomorphism , nucleoli , chromatin granularity , and chromatin 
 density scored from 1 to 3 and total in the range of 69 , 10 - 11 , and 1219 as grades 
 i , ii , and iii , respectively . mouriquand and pasquier   ( figure 9 ) gave a score of 03 to cellular and nuclear features , chromatin 
 and mitosis and graded as i if total score was < 5 , ii if in the range of 69 , and 
 iii if > 10 . howell 's system   ( figures 10 and 11 ) is similar to 
 the scarff - bloom - richardson histological grading with modification to the mitotic count as score 1 
 for 0 - 1/10 high power fields , 2 for 24/10  hpf , and 3 for > 5/10  hpf . grades were allotted as i , ii , and iii for scores in the range of 35 , 6 - 7 , and 8 - 9 , 
 respectively . the corresponding h&e stained sections of the formalin - fixed , paraffin embedded blocks of 
 post - operative mastectomy specimens were studied and the histological grading done by nottingham 
 modification of scarff - bloom - richardson 's method 
 ( figures 12 , 13 , and 
 14 ) . mitotic figures were counted and scored using an 
 olympus ch20i microscope with high power field diameter of 0.45  mm . the results were tabulated and statistical analyses were done with the ibm spss statistics 
 software , version 20 . majority of the cases were grade ii 
 ( 44 out of 72 cases ) . the distribution of cases according to the cytological grading systems and 
 histological grading is listed in table 1 . the association between each of the cytological grading systems and the histological grading was 
 found to be highly significant with a p value of < 0.001 , as measured by the 
 chi - square test . the correlation and concordance analyses between the cytological grading and 
 histological grading were as in table 2 . all the 7 cytological grading systems correlated well with the histological grading , as 
 calculated by spearman 's correlation coefficient (  ) . robinson 's system 
 showed the highest concordance ( 56 out of 72 cases , 77.7% ) and agreement (  
 value 0.61 , substantial agreement ) , with the histological grading , closely followed by fisher 's 
 system ( 55 out of 72 cases , 76.3% and  = 0.526 , moderate agreement ) , 
 whereas taniguchi 's system showed the least concordance ( 48 out of 72 cases , 66.6% ) but fair 
 agreement with kappa value of 0.401 . the interobserver agreement was analysed by kappa measurement of agreement and the result 
 observed was recorded in table 3 . fisher 's system 
 showed the highest concordance ( 61 out of 72 cases , 84.7% ,  = 0.616 ) of 
 grading between the two pathologists , followed by robinson ( 83.3% ) , dabbs and silverman ( 80.5% ) , and 
 taniguchi ( 80.5% ) systems . fine - needle aspiration cytology plays a major role in the primary diagnosis of breast carcinoma . cytological grading of the smears can provide valuable prognostic information and aid in planning 
 the management options . several grading systems have been proposed by various authors , but none have 
 been implemented successfully in routine practice . this study was done with the aim of finding a 
 reliable cytological grading system which is not only simple and effective , but also better agreed 
 among the reporting pathologists . various studies have highlighted the benefits of robinson 's system , but fewer studies have 
 considered other three - tier systems of cytological grading . in this study , we have compared 7 
 three - tier cytological grading systems with the histological grading and also the interobserver 
 agreement . to increase the credibility of the assessment , interobserver agreement for histological 
 grading our results proved to be in favour of 
 robinson 's system ; however , fisher 's system has also shown to be a good alternative . different studies in the past have shown varying concordance between cytological and histological 
 grading . 70.18% and in the present study 76.3% of concordance , between fisher 's system and histological 
 grading . comparison studies between robinson 's grading and histological grading showed agreement of 57% by 
 robinson et al . , 80.76% by das et al . , 88.89% by bhargava et al . , 
 65% by chhabra et al . , 83% by meena et al . , 88% by khan et al . , 
 81% by sinha et al . , 64% by lingegowda et al . , 77.19% by saha et al . , and 77.7% in the present study . the advantage of this system is that the effect of 
 individual variation in the evaluation of a single component of the system is reduced by analysis of 
 the other components , as stressed by dalton et al . . we observed concordance of 72.2% for dabbs and silverman grading with histological grading , 
 whereas dabbs and silverman   observed 87% . khan et al . 
  found concordance of 97.14% for the grading system 
 proposed by them , but in the present study , we observed 72.2% . taniguchi 's system yielded 
 concordance of 66.6% in our study , whereas taniguchi et al .   observed 44.4% only . compared robinson 's and mouriquand systems 
 with the histological grading and observed similar results ( 71.2% concordance ) but considered 
 robinson 's method as a better choice due to its simplicity , specificity , and better reproducibility . our study showed a concordance rate of 68% for mouriquand 's system and 69.4% for howell 's system , 
 whereas it was 57.1% by howell et al . , 50% by bhargava 
 et al . , 82% by lingegowda et al . , and 63.16% by saha et al . 
 for howell 's grading , which was a modification of the nottingham 's scarff - bloom - richardson 
 grading howell et al .   found inter - observer agreement of 74.3% for histological grading and 
 65.7% for cytological grading , lingegowda et al .   found 
 98% interobserver agreement for robinson 's system the study by 
 saha et al .   showed an interobserver agreement of 78.95% 
 for fisher 's system , 84.21% for mouriquand 's , 77.19% for robinson 's , 85.96% for howell 's , 80.70% for 
 khan 's , and 80.70% for taniguchi 's systems . in comparison , our study had 84.7% for fisher 's , 83.3% 
 for robinson 's , 80.5% for dabbs ' , 79.1% for khan 's , 80.5% for taniguchi 's , 76.3% for mouriquand 's , 
 and 75% for howell 's system . as it is also an important 
 criterion for diagnosis of malignancy , once the diagnosis of malignancy is established , the smear 
 will show a score of 2 for cellular pattern . but various authors had determined by regression 
 analysis , extent of cell dissociation as the most influential factor for scoring along with the 
 appearance of nucleoli . subtle degrees of nuclear pleomorphism and loss of cell - to - cell cohesion 
 were difficult to score , resulting in minor discrepancies . also , we felt difficulty in detecting 
 mitosis in the aspiration smears , as observed by howell et al .   too . this may be due to the fact that , in cytological smears , the material aspirated is 
 very less compared to that available in histological sections . other factors which contributed to difficulty in grading included poor quality slides with 
 fixation artifacts and tumours with necrosis or severe inflammation . we propose that it be included in fnac reports of breast malignancies . in the present study , all the 
 seven cytological grading systems correlated positively with the histological grading . however , 
 robinson 's method showed a better correlation and substantial kappa value of agreement with the 
 histological grading in comparison to the other methods . this is because of the multifactorial 
 nature of the system . according to our study , robinson 's method of cytological grading in fine 
 needle aspiration smears of breast carcinoma is simpler , objective and easily reproducible , hence 
 being preferable for routine use .
background . fine - needle aspiration cytology plays a major role in the primary 
 diagnosis of breast carcinoma . 
 cytological grading of the smears can provide valuable prognostic 
 information and aid in planning the management options . 
 aim . to evaluate various 
 3-tier cytological grading systems and to determine the best possible system which is reliable and 
 objective for use in routine practice . 
 materials & methods . 
 72 fine - needle 
 aspiration smears of breast carcinomas were graded by two pathologists and compared with the 
 histologic grading by nottingham modification of scarff - bloom - richardson method . 
 concordance and 
 correlation studies were done . 
 kappa measurement of interobserver agreement was also done . 
 results . 
 robinson 's method showed a better correlation ( 77.7% ) and substantial 
 kappa value of agreement (  = 0.61 ) with bloom richardson 's histological 
 grading method in comparison to the other methods , closely followed by fisher 's method . 
 fisher 's 
 method showed better interobserver agreement ( 84.7% ,  = 0.616 ) compared to 
 the other systems . 
 conclusions . 
 robinson 's method of cytological grading in 
 fine - needle aspiration smears of breast carcinoma is simpler , multifactorial , and feasible , hence 
 being preferable for routine use according to our study .