Evaluation of an Advanced Nine-Parameter Cytomorphological Grading System for Improving Preoperative Accuracy and Histopathological Correlation in Breast Carcinoma

Introduction: Preoperative cytological grading of breast carcinoma plays an indispensable role in guiding clinical staging, surgical management, and neoadjuvant therapy.While standardized classifications like the National Cancer Institute Bethesda guidelines and the International Academy of Cytology (IAC) Yokohama system provide consistent five-tier reporting, diagnostic gray zones persist, and established six-parameter frameworks (e.g., Robinson's criteria) often lack the biological nuance required to evaluate borderline and high-grade tumors.The primary objective of this prospective study was to evaluate an improvised nineparameter cytomorphological grading framework (scores 9 to 27) applied specifically to invasive breast carcinomas and assess its agreement against postoperative modified Bloom-Richardson histological grades in patients with available surgical specimens, while secondarily comparing performance directly against Robinson's system.Materials and methods: Fine-needle aspiration cytology (FNAC) was performed on 106 female patients presenting with palpable breast lumps between July 15, 2024, and July 14, 2026.Cytological smears were stained with Papanicolaou and Leishman-Giemsa stains.Smears fulfilling the adequacy requirement of at least six distinct epithelial clusters were classified into five tiers.Confirmed malignant aspirates were graded using an improvised nine-parameter scoring rubric (scores 9 to 27) structured into distinct, non-overlapping tiers: Grade I (9-13), Grade II (14-20), and Grade III (21-27), evaluating epithelial and myoepithelial distribution, cluster cohesiveness, and margin irregularities along with nuclear characteristics.Findings were statistically correlated against histopathological grades in 50 surgical mastectomy specimens.Intermethod agreement was evaluated using linear weighted Cohen's kappa (kappa w) with standard error (SE) and 95% confidence intervals (CI).Results: The cohort was categorized into 52 benign cases, four atypical/suspicious cases, and 50 malignant cases.The nine-parameter system classified malignant lesions into 11 Grade I cases, 31 Grade II cases, and eight Grade III cases.Concordance with modified Bloom-Richardson histological grades was statistically significant (chi square = 238.2,p < 0.001), yielding an overall concordance of 92.0% (46/50), a linear weighted kappa (kappa w) of 0.908 (95% CI: 0.812-1.000;SE = 0.049), and an unweighted kappa (kappa) of 0.865 (95% CI: 0.741-0.989),with a 100% concordance rate for Grade III lesions.In comparison, Robinson's criteria evaluated across the same 50 cases demonstrated 78.0% concordance (39/50) with kappa w = 0.694 (95% CI: 0.528-0.860).Conclusions: The improvised nine-parameter cytomorphological system demonstrated strong concordance with histological tumor grade in this single-center cohort, showing improved stratification of intermediategrade lesions compared with Robinson's criteria.Because evaluation was restricted to 50 surgically treated patients without concurrent biomarker assessment (ER, PR, HER2, and Ki-67) or formal multi-observer reproducibility testing, findings should be regarded as preliminary, and multi-center external validation is necessary before recommending routine clinical implementation.