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Fine Needle Aspiration and Lymphoma Question

So I finally got my FNA done, it was done at Mayo hospital in Minnesota, which is incredibly well renown. The biopsy was performed by a Dr who does nothing but FNA ultrasound biopsies of lymph nodes, cysts etc and was also a radiologist herself. So in the past I mentioned how I had a string of about 5 nodes on the left side of my neck and 3 along the front left of my neck along my jugular/ under my chin. She however said all of those were too small to biopsy, she did say they weren’t concerning to her. However she said the note simply said to biopsy the largest node on the left side of my neck. So she went ahead and biopsies a lymph node along my jaw that was too deep for me to feel. This somewhat concerned me as what was being biopsied was not one of the new slightly swollen nodes that alarmed me in the first place (unless it was swollen and just in a non palpable location deeper in) she did say it was larger than the rest but that was normal underneath the jaw area. Again she said this wasn’t concerning either and she was just choosing the largest as per the order. So she took 11 samples of the node and sent me on my way. Two hours later I got a call saying they had examined the sample and it showed no sign of malignancy or lymphoma. They also said I should be happy and that this was about as absolute as it’s gets.

My only concern is that what was biopsied wasn’t one of the lymph nodes I noticed swell up, it may have been the largest but may have not been enlarged like the others compared to their original size. I guess my question is, can I trust that biopsy then? It was within a couple inches range of all the others, which I would assume a malignancy would be present in the whole area given it’s all over the area that are palpable, or is that not the case? Can I trust the biopsy given it was a node I had not noticed was even enlarged but still right next to the others, just much deeper?

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1081992 tn?1389903637
COMMUNITY LEADER
The interventional radiologist that did the FNA said that "it was larger than the rest but that was normal underneath the jaw area".

Submandibular nodes do tend to be larger and rounder than other neck nodes. But if it's larger than the palpably enlarged neck nodes, then probably it is indeed enlarged from it's own resting state - while still in "normal", not-cancer range. (But can you find out the actual dimensions, to be sure? There has to be paperwork on the procedure somewhere.)

11 sticks with the needle is a lot, so that also argues in favor of the node being enlarged.

"It was within a couple inches range of all the others..."
That's how HL spreads (though not necessarily NHL).

"...just much deeper?"
Yes, you probably didn't feel that one because it is deeper - not because it is un-enlarged.
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2 Comments
Well the radiologist told me none of the nodes looked concerning to her, she also mention the 11 samples were taken because she was concerned about getting a good sample given it’s size (which I’m assuming means it was still considered small) but the call said that the sample must have been good because no notes were made about trouble with the amount of samples or quality etc. should o request the report? They did say it looked clear and ‘shows no evidence of malignancy or lymphoma’ and told me that’s as definitive as it comes. So I’ll still request the report if you think it’s worth a peek. Overall though do you agree this should put my mind to rest?
And I guess even if the node wasn’t necessarily enlarged like the others that should still rule out the vast majority of malignancies and lymphoma given how many beneath it on the jugular and cervical chain in close proximity are the ones affected?
1081992 tn?1389903637
COMMUNITY LEADER
It was very considerate of them to give you a call so soon.

Don't forget to post the biopsy report when that is available.
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1081992 tn?1389903637
COMMUNITY LEADER
"Overall though do you agree this should put my mind to rest?"
Yes, it is further evidence of not-cancer.

I would like to see only the dimensions, though. Maybe somebody could read that over the phone to you. To me, 11 times means it was large and she wanted to hit every area of it. To me, 11 times also means she didn't see any unusual spots inside of it - or she would have aimed for those spots.

She didn't see any bad new blood vessels on Doppler, either.

As for the actual path report, which is separate, I'd like to see if they looked for inflammation indicators. I'll say again that I am not a doctor but it sure looks like inflammation and fibrosis to me.
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5 Comments
Okay, I’ll ask for records sent out of the preliminary ultrasound and I’ll let you know what they say. I should mention in the past I do remember being told that the largest node seen was under 1 cm and recently they said a couple actually looked slightly smaller. (Which I would assume is a good sign?)
1 cm in the short axis is enlarged, but is just under the limit of being "normal" aka not-cancer.

If they each got to ~1cm, and then grew no further, that is a good sign.
'1 cm in the short axis is enlarged, but is just under the limit of being "normal" aka not-cancer.'
As always, those are tendencies and not absolutes.
This was the long axis, I think the largest was .8 cm they said. Also given it’s been literally 10 months now, with the only chance being a couple nodes are slightly smaller, doesn’t that rule out most cancers as well? Even slow growing would have progressed to swelling the nodes further wouldn’t it have?
Only change* not chance
1081992 tn?1389903637
COMMUNITY LEADER
"Even slow growing would have progressed to swelling the nodes further wouldn’t it have?"
Yes, most probably.

In addition, if each node enlarged very quickly, like overnight, then suddenly stopped growing? That would be very, very hard to associate with how cancer behaves. (Fast, then stop.) But that's exactly how a reactive node, followed by scarring, could behave.

Btw, did we rule out teeth/gum problems as the origination?
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3 Comments
I do have a couple cavities that need filled but two ENT’s and my dentist have all said my mouth looks healthy. I even have my wisdom teeth since I have enough room, I’ve always been told my oral health is fantastic. I did notice a couple little bumps in the gum that were mobile and flesh colored but the ENT and dentist both said it looked normal when I pointed them out. Unless a cavity/sensitive tooth could cause it?
I also should mention I can feel several nodes in my crotch region, they feel just a little bigger than my neck ones but from my understanding that’s normal for the area-also they are symmetrical so I’m guessing those are completely healthy nodes.

My only wonder is if muscle strains can cause lymph node swelling? The morning of the day I noticed them I woke up with my head bent at an un-Godly angle against the arm of the couch, the left side of my neck was super sore and stiff the whole day-which is why I noticed the nodes, I was rubbing the sore neck. It’s a stretch but can muscle strain cause enlargement?
I also should mention I can feel several nodes in my crotch region, they feel just a little bigger than my neck ones but from my understanding that’s normal for the area-also they are symmetrical so I’m guessing those are completely healthy nodes.

My only wonder is if muscle strains can cause lymph node swelling? The morning of the day I noticed them I woke up with my head bent at an un-Godly angle against the arm of the couch, the left side of my neck was super sore and stiff the whole day-which is why I noticed the nodes, I was rubbing the sore neck. It’s a stretch but can muscle strain cause enlargement?
1081992 tn?1389903637
COMMUNITY LEADER
"Unless a cavity/sensitive tooth could cause it?"
Yes, that can. There can also be an occult infection in/around the root, which can send biochemical signals down the lymphatic drainage in the neck.
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1081992 tn?1389903637
COMMUNITY LEADER
"I also should mention I can feel several nodes in my crotch region..."
Whoa! Do the doctors know that? Was there an ultrasound? Post that. This is "generalized lymphadenopathy" (2 regions), which is a higher level of concern.

"normal for the area..."
They are naturally larger when enlarged; but being palpable means something is going on there.

I still think it's not-cancer, but the odds of getting an excisional biopsy are now increased - to find the actual cause.

"they are symmetrical so I’m guessing those are completely healthy nodes"
Not really; generally oval is good, round is not good. But round is not automatically cancer.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3551661/
"Ultrasound morphology of inguinal lymph nodes may not herald an associated pathology"
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1081992 tn?1389903637
COMMUNITY LEADER
"can muscle strain cause enlargement?"
Not really, but trauma certainly can - including 'crush trauma'.

Pain chemicals likely can, especially with a hyper reactive immune system.
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1081992 tn?1389903637
COMMUNITY LEADER
Where is the latest report from the neck ultrasound?
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1081992 tn?1389903637
COMMUNITY LEADER
Do you flush-red/blush a lot? Have anything like asthma?
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3 Comments
No, when I was a kid they thought I had asthma but outgrew it,  I flush when nervous or surprised but nothing out of the norm. The doc has actually felt the groun region and said they didn’t feel enlarged or out of the norm. And I’ve always heard that nodes along the groin region could be felt in skinny people, that is most definitely me (138lbs) I’ll mention it to him again at my follow up on the 7th but no ultrasound there as of yet.
Also when I said they are symmetrical I don’t mean they are rounded, they are long ovals but are symmetrical in that on each side of the groin they are present in the same places and at the same sizes
http://www.bad.org.uk/for-the-public/patient-information-leaflets/how-to-check-you-lymph-nodes/?showmore=1&returnlink=http%3A%2F%2Fbad.org.uk%2Ffor-the-public%2Fpatient-information-leaflets#.XYPqoaROmEc

I definitely qualify as skinny like it says, I have a 28 inch waist. I’ll bring it up and request an ultrasound but both sides feel the same exact size and shape etc.
1081992 tn?1389903637
COMMUNITY LEADER
"The doc has actually felt the groun region and said they didn’t feel enlarged or out of the norm."
Okay, then we can discard the notion of generalized lymphadenopathy. I wouldn't ask for the sono, even more so because "they are symmetrical in that on each side of the groin they are present in the same places and at the same sizes"

The doc would rightly feel that asking for a sono there is unreasonable.
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3 Comments
Okay, today I actually noticed a small pea sized lymph node on my upper jugular when feeling the sore area from the FNA, however again I feel a small pea sized lump in nearly the same spot on the other side too, so I assume that as well is one that is provably normally present?
Yes, your thinking sounds generally correct.
Seen the ENT today again, he said that if I was still worried he would do an excisional biopsy and remove a couple of them for peace of mind. He does the surgery I guess, he said I would only be out a few minutes and it would be an easy thing. He said he doesn’t think I need it but he can see my worry over the situation. He is sending me to a hematologist as well since my WBC count has routinely been low since I’ve beeb an adult, he did say that too was for peace of mind. I haven’t agreed to the biopsy, I figured I’d wait for the three month follow up ultrasound and hematology appointment but what do you think here?
1081992 tn?1389903637
COMMUNITY LEADER
"I figured I’d wait for the three month follow up ultrasound and hematology appointment but what do you think here?"

The biopsy might reveal the real cause of the node problem. Or, it might say that "there is an inflammatory process of unknown etiology".

The biopsy can't 100% rule out cancer anyway because the mind can then always shift to thinking that it's the "other" nodes that should have been excised and tested.

Overall, I'd choose to wait, as you are planning to do.

As for low WBC, have you looked into hypoalbuminemia?
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1 Comments
I still know it would help because to me if it was an enlarged node it would assuredly be affected by whatever caused the initial swelling, actually even the fine needle really puts me at ease because it still sound like a 70% shot it would find even something like hodgkins.

Anyway, the WBC has occasionally been slightly low a few times, the range at the labs typically are 4.5-11 normal range, mine have numerous times been 4.2 or 4.4 etc when it is normal it’s like 4.7 or 4.8. The only time it was higher was during that bad chest infection, in which case it was right in the middle I believe. Now my doctor knows this and said it’s not uncommon for healthy people to have a lightly low count, it can actually be a sign of very good health (which I read up on and it sounds like that’s true to some extent in some people) and it’s not like I’m suffering any symptoms-i don’t have frequent infections, I get two viral infections a year for about a week and am back in gear. I do have low vitamin D a lot which I have heard can affect WBC production though. I did have liver tests recently and my numbers were all great.
1081992 tn?1389903637
COMMUNITY LEADER
"it can actually be a sign of very good health"

Yep. As long as there is no identifiable pathology causing it, it can be seen as a sign of low systemic inflammation.


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1 Comments
So the hematologist appointment went good, they said my biggest node was I think .9mm by 2mm I think. Anyway no concern really however they said if I wanted I should do the excision for peace of mind. They said they can do it under local but the ent said general anesthesia?

Anyway only thing they mentioned was my slightly low B12 and my ANA for autoimmune was 1.7 with 1 being the normal range. They said they weren’t worried because nothing else pinged on the autoimmune panel and they said it’s fairly common for completely healthy people to show slightly elevated ANA as it’s a pretty loose diagnostic tool.

Anyway any thoughts? If it’s just local numbing I would definitely do it but general I would think a bit but probably would. Also any concern about the ANA? I figured with my family history (which they were aware of) it would be a huge concern but they didn’t seem bothered at all.
1081992 tn?1389903637
COMMUNITY LEADER
The shape of your node is very good, as you know.

Yes, ANA is a fuzzy thing. A normal, healthy person can indeed have elevated ANA - then there is the pattern, such as speckled, etc.

If you wanted to evaluate any possible downside, it might be contained in something like this:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132017/
"Risk factors for ANA positivity in healthy persons"
But I wouldn't be concerned at this point, and regard the ANA as just another sign of unusual, lifetime baseline immunity.

I would do the biopsy only if the pathologist would also be instructed to look for all inflammatory cells, and granulomas. Maybe even special stain for mast cells. Do you think you might have a lot of anxiety under local? Maybe ask for twilight anesthesia - and I'd alert any anesthesiologist that "I have a very reactive immune system", so they are on guard.

After the biopsy, definitely ask any medico who visits you, "How did it look (grossly)?" and wait for them to say "normal". Good luck and let me know how it goes.
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2 Comments
Well I’ve had general anesthesia as a child a couple times so while it’s been awhile I have had it before with no issues so I would assume that still stands as me being in the clear? . Also I wouldn’t have much anxiety. My anxiety stems more from being put under than the procedure itself. I like being in control, awake I would be and I’d hold still, anesthesia is very much not in control if that makes sense. Seriously I’ve jumped out of a plane and loved it, but put me infront of a doctor and I’m hyperventilating, because something could be going on I can’t control, so in this case I trust the doctor to do the mostly simple procudure.

I’ll let you know what happens next! Thanks for your help by the way!
Also the hematologist said that one thing that was very reassuring was the fact they weren’t growing. He didn’t have access to all the unltraslunds results but I know every time they’ve said they weren’t growing infact On͏e said a couple shrank just a bit. He said even in Hodgkins or the slowest growing, follicular lymphoma, while symptoms take years to develop in some cases, once the cancer is in a node (which hypothetically they enlarged node would have it should I have cancer) it would most definitely have at least doubled in size in a year he said. He said even though something is slow growing it would still be expected to have growth over a few months or even weeks let alone a year. Does that line up with what you’ve heard as well?
1081992 tn?1389903637
COMMUNITY LEADER
"...so I would assume that still stands as me being in the clear?"
Yes, I would guess that is probably true.

"My anxiety stems more from being put under than the procedure itself. I like being in control, awake I would be and I’d hold still, anesthesia is very much not in control if that makes sense."
Okay, that is perfectly understandable.

"Also the hematologist said that one thing that was very reassuring was the fact they weren’t growing."
Yes, I've also said that to you more than once. That comes under the heading of 'behavior'. That's especially true if the node grew overnight, or nearly that fast - then it would be extremely rare and almost miraculous for it to then stop growing. But growing overnight and plateauing is typical behavior of a reactive node. That's why I ask almost everybody if it grew overnight.

"...it would most definitely have at least doubled in size in a year he said... Does that line up with what you’ve heard as well?"
Double? No, not true at all from what I have heard but also seen. Did you possibly misunderstand the hema?

"Thanks for your help by the way!"
You're welcome  :)
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2 Comments
He seemed pretty confident in his saying he would have expected it to grow at least. It’s possible in that sentence he meant the more common lymphomas but he did say even follicular, which according to him is the slowest growing lymphoma even moreso than Hodgkins, there would at least be defintelg noticeable changes within the course of a year and given my frequent ultrasounds that would have been picked up on. Do you agree with that part at least regarding the low grade indolent lymphomas?
Do you agree that there would be at least a definite noticeable change in lymph node sixes after a year even in slow growing?

Also my ANA being 1:70 I asked the NP who ran it and she said the “verifying test came back negative” what does that mean? Is it true that most people with ANA are fine? It just seems like such a fluke deal but with my family history.
1081992 tn?1389903637
COMMUNITY LEADER
"Do you agree that there would be at least a definite noticeable change in lymph node sixes after a year even in slow growing?"
Very probably. Almost certainly. But still, these types of questions are a matter of probabilities. IMO, the most improbable scenario is that a cancer grows fast at the beginning, then turns to not-growing at all.

Theoretically, a cancer can do almost anything, and so can the immune system. A cancer is thought of as a mutation in a gene, but in a practical sense it's really an accumulation of mutations - and each new mutation can change behavior which usually makes the cancer worse.

The immune system can be not-killing, then suddenly (and very rarely) become able to detect and kill a cancer - maybe sometimes just because you got a cold and that changed your immune cells. (Anti-cancer vaccines are meant to work the same way.)

Even with a full excisional biopsy, there are rare times when it's not known what type of cancer is present, or if there really is a cancer. More uncertainty.

I've always aimed to give you the most truthful answers, and not merely the most positive answers (which could be less accurate). So when I say that I don't think you have a cancer, I'm not just being reassuring for it's own sake. That said, I'll also state that benign inflammation predisposes somewhat to developing a cancer, mainly because of the increased cell division as immune cells proliferate. That's another reason for a biopsy to look for whatever inflammatory cells are present.


A side note: CT is more accurate on sizing than US. But that's not so relevamt for your case, I just mention it to be thorough.
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1081992 tn?1389903637
COMMUNITY LEADER
'Also my ANA being 1:70 I asked the NP who ran it and she said the “verifying test came back negative” what does that mean?'
Probably that, since sometimes a test can just go bad for various reasons, a second test is done to see if it agrees with the first one.
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1081992 tn?1389903637
COMMUNITY LEADER
"Is it true that most people with ANA are fine?"
Probably, yes. And there's even this: "[antinuclear antibodies] Moreover, the deficiency of vitamin D in the body of patients correlates with occurrence of these antibodies."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6142026/

You could websearch--> positive predictive value ANA

to get more and more complexity.

"It just seems like such a fluke deal but with my family history."
Yep. So never compare yourself to averages -- unless they are the averages of people with unusual immune systems.  Usually :)


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2 Comments
Alright thank you, one thing I should mention is that the Hema did make a mention to me none of my nodes are considered enlarged just prominent. He wasn’t necessarily doubting me that they were bigger than originally stated but did say under US they were all under a cm and that had I came in for something else and he done the exam physically he wouldn’t even have mentioned them upon feeling them.

With US I’m assuming it would still be able to see if there was growth compared to the previous US at least pretty clearly? At this point that seems to be the biggest factor. I will say the Dr did mention sometimes even minor dental issues can cause nodes to ever so slightly enlarge without any pain etc more annoyed than reactive he said. So he said I should get those couple minor cavities worked on and see what happens given some are under the jaw. My dentist claimed only a serious infection can do that but I’m sure the Hema would be much more familiar with lymph node behavior.
And with my ANA you wouldn’t have concerns even with the family history? I will ask my doctor more but if the verifying test came back negative and that was the same test I guess that means I may not even have it? Sorry if I seem confused I kind of am. Everything I’ve read about that test seems to go every direction.
1081992 tn?1389903637
COMMUNITY LEADER
Generally, the US is more of a fuzzy image:  
https://www.startpage.com/sp/search?language=english&lui=english&t=default&query=lymph+node+sonogram&cat=pics

But a CT is sharp. US is also more prone to operator variability. Even so, the series of USs *would* detect gradual enlargement.


I think shape is more important than size, because a small round node might be cancer. (but submandibulars are more rounded naturally).

"At this point that seems to be the biggest factor."
I don't recall, did you ever say if the hilum is present?


"even minor dental issues can cause nodes to ever so slightly enlarge..."
I don't see why it couldn't even be significant enlargement, if a tooth is pumping pro-inflammatory biochemicals downstream to nodes. There would also be immune cells by a tooth, that make shredded pieces of bacteria they'd encountered, then go downstream to nodes with that -- so as to tell other immune cells: proliferate and kill these things.

I'm fairly sure I'd mentioned 'dental' to you about a month or two ago, as a possibility.

"My dentist claimed only a serious infection can do that"
In normals? What about in highly reactive people? (Can eating one peanut or sesame seed kill a person?)

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1081992 tn?1389903637
COMMUNITY LEADER
"And with my ANA you wouldn’t have concerns even with the family history?"
To the contrary, with your Hx and Fx I'd rather expect elevated ANA. But not really high ANA.

"...if the verifying test came back negative and that was the same test I guess that means I may not even have it?"
Yep. Unless the 2nd test was a false negative. Or your internal state might change over time, so each test was correct at it's own moment in time.

"Sorry if I seem confused I kind of am."
Good :)  That is the natural result of delving into this thoroughly, instead of just shrugging it off - as most people would. It's a lot to absorb and you are doing very well at it.

"Everything I’ve read about that test seems to go every direction."
Yep. Just think of the ANA as suggestive, not definitive.
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1 Comments
But I only had one blood draw for this test, so is it possible for them to perform a verifying test on the same sample?
1081992 tn?1389903637
COMMUNITY LEADER
"But I only had one blood draw for this test, so is it possible for them to perform a verifying test on the same sample?"
Some substances being tested for in blood or urine samples quickly degrade. Degradation might be prevented/delayed by refrigeration. For biopsy samples, preservatives or freezing can be used. When antibodies themselves are used as a treatment, they arrive freeze dried. Other than all that, I don't know.

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2 Comments
Alright, uncles she meant the antibody panel was the verifying which I doubt it. Now one thing I’m confused on, it says ANA is measured as a positive or negative then a titer. Such as 1:40 to 1:640 etc but the results say the range is anything above 1 being abnormal and I was 1.7, does that mean I’m 1:70 or 1:700? I’m not sure how to interpret those results that seem like the measurement is off from what most sources say
Unless* sorry. But I would assume that means I don’t have positive Ana in that case. I will get my teeth looked over again (I only have 3 minor cavities but who knows it’s worth getting looked at before an excision) I should mention I don’t have any other aspects of overactive immune system. Really the only allergy I have not is to a particular weed and penicillin which from what I understand is a fairly common allergy.
1081992 tn?1389903637
COMMUNITY LEADER
Without seeing the report, I'd think that the 1.7 is the concentration (e.g. ug/ml) of a specific antibody subtype.

The ratio notation  (e.g. 1:1000 is a thousand to one) is the dilution of the sample.
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2 Comments
There was no note of dilution, it just says 1.7 which I assumed was 1:70
But I did find this interesting article stating the test for titer is usually only ran on anything 3.0 or up as the lower level serum tests often come back negative upon retesting. Me being at 1.7 certainly fit that figure.

https://neurology.testcatalog.org/show/ANA2
1081992 tn?1389903637
COMMUNITY LEADER
They are always diluted. AFAIK, they dilute until the glowing Ab's are no longer detected. Then they might next measure the concentration of selected subtypes of AN antibodies. (ANA is a collection of various Ab's.) That's the classic way, there might be newer ways.

Very roughly, it goes like this:
- antibodies bind to antigens
- they line a dish with cells that have lots of suitable antigens
- they dilute and then add your blood to the dish
- any ANAs in your blood bind to the antigens in the cells
- they rinse the dish, the bound AB's remain
- they add a molecule that glows under fluorescent light to the tail ends of the bound Ab's
- they shine a fluorescent light and observe the microscopic pattern of the glowing dots

Very roughly.

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