Case-based Review of Subtle Signs of Breast Cancer at Mammography

HomeRadioGraphicsVol. 39, No. 3 PreviousNext Breast ImagingFree AccessRadioGraphics Fundamentals | Online PresentationCase-based Review of Subtle Signs of Breast Cancer at MammographyMonica M. Sheth1 , Suzanne E. McElligottMonica M. Sheth1 , Suzanne E. McElligottAuthor AffiliationsFrom the Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.Address correspondence to M.M.S. (e-mail: [email protected]).Monica M. Sheth1 Suzanne E. McElligottPublished Online:May 6 2019https://doi.org/10.1148/rg.2019180147MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In AbstractThe full digital presentation is available online.Screening mammography has been repeatedly shown to reduce breast cancer mortality by up to 40% and is associated with decreased stage at diagnosis and receipt of less extensive treatment. Although it is the standard for breast cancer screening, mammography is not perfect, and 10%–30% of breast cancers can be missed at mammography. As radiologists, we aim to detect breast cancer prior to the development of clinical symptoms at an earlier and more easily treatable stage. If breast cancer is undetected at mammography, patients can experience a delay in diagnosis and treatment and may potentially have an altered prognosis.Multiple factors can contribute to missed breast cancer:1. Dense parenchyma: Dense parenchyma has a masking effect, which makes underlying cancer harder to detect.2. Suboptimal positioning or technique: This can make the detection of findings more challenging, particularly when the cancer is small, subtle, or located at the edge of the image or entirely outside of the field of view. Proper positioning maximizes the amount of breast tissue being imaged, eliminates the majority of artifacts, and increases sensitivity for detection at mammography.3. Cancer type: The nature of the cancer itself plays a role in its detectability. A small percentage of breast cancers are slow growing, have a relatively stable appearance over several years at mammography, and fail to incite a desmoplastic reaction.4. Perception and interpretation errors: Missed cancers may also be the result of the radiologist’s perception or interpretation errors, which allow the finding to be overlooked or dismissed as nonworrisome, respectively.Through a series of cases in this online presentation, we illustrate how radiologists can recognize and overcome many of the causal factors of missed breast cancers. Radiologists can enhance their diagnostic accuracy and clinical acumen by following three broad concepts: (a) paying meticulous attention to technique and positioning, (b) developing a standard search pattern, and (c) comparing the current examination to multiple prior examinations, when available.In this presentation, we evaluate positioning and technique and encourage radiologists to ask these questions: Is the nipple in profile on at least one view? Is the inframammary fold open? Is there a 1 cm or less difference in the posterior nipple line measurement on the craniocaudal (CC) and mediolateral-oblique (MLO) views? Are there any signs of blurring to suggest motion artifact? The answers to such questions will allow the radiologist to determine the technical adequacy of the examination and aid in the detection of breast cancer, as breast cancer cannot be visualized if it is not imaged.Developing and maintaining an all-inclusive search pattern while interpreting mammographic examinations is essential to avoid missing subtle signs of breast cancer that can be easily overlooked or hard to visualize. The radiologist’s search pattern should include the anterior and posterior fat-glandular interface (Fig 1), edge of an image (Fig 2), axillary tail and axilla, retroglandular fat, inner and lower triangles, skin, and nipple-areolar complex.Figure 1. MLO mammogram shows a focal asymmetry (circle) in a patient with scattered fibroglandular tissue, with a new convex contour deformity (red line) anteriorly located. Subtle signs of bulging at the anterior fat-glandular interface should be evaluated, as the border usually has a scalloped contour in women with scattered fibroglandular tissue. The results of a biopsy confirmed invasive cancer.Figure 1.Download as PowerPointOpen in Image Viewer Figure 2. CC mammogram shows a subtle asymmetry (square) within the central posterior breast, a finding that highlights the importance of evaluating the edge of images, as subtle changes in tissue pattern can be depicted here. If the findings are real, they may represent only a small portion of the malignancy. In this case, the asymmetry was missed and only identified in retrospect the following year when the finding was much larger. The results of a biopsy confirmed invasive tubulolobular carcinoma.Figure 2.Download as PowerPointOpen in Image Viewer Comparing multiple prior examinations can help identify subtle changes in tissue patterns over time such as parenchymal asymmetries, architectural distortion, calcifications, new or enlarging masses or lymph nodes, and changes in the postsurgical breast. By adhering to these concepts, radiologists can potentially decrease their false-negative rates at screening mammography.M.M.S. supported by the RSNA Research and Education Foundation (RSNA Education Scholar Grant ESCH1713).Presented as an education exhibit at the 2017 RSNA Annual Meeting.All authors have disclosed no relevant relationships.1 Current address: Department of Radiology, NYU Langone Health, 660 First Avenue, 3rd Floor, New York, NY 11016.Suggested Readings Goergen S , Evans J , Cohen G , MacMillan J . Characteristics of breast carcinomas missed by screening radiologists . 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Crossref, Medline, Google ScholarArticle HistoryReceived: Apr 12 2018Revision requested: May 31 2018Revision received: Aug 1 2018Accepted: Aug 6 2018Published online: May 06 2019Published in print: May 2019 FiguresReferencesRelatedDetailsCited BySubtle signs of breast cancer as an important pitfall in mammographic interpretation: Establishing an accurate diagnosis in an equivocal caseNikolaos S.Salemis, EleniMourtzoukou, MichailAngelopoulos2021 | Breast Disease, Vol. 40, No. 3Accompanying This ArticleCase-based Review of Subtle Signs of Breast Cancer at MammographyMay 6 2019Default Digital Object SeriesRecommended Articles Missed Breast Cancer: Effects of Subconscious Bias and Lesion CharacteristicsRadioGraphics2020Volume: 40Issue: 4pp. 941-960Digital Breast Tomosynthesis: Concepts and Clinical PracticeRadiology2019Volume: 292Issue: 1pp. 1-14Developing Asymmetries at Mammography: A Multimodality Approach to Assessment and ManagementRadioGraphics2016Volume: 36Issue: 2pp. 322-334Strengths and Weaknesses of Synthetic Mammography in ScreeningRadioGraphics2017Volume: 37Issue: 7pp. 1913-1927Nipple-sparing Mastectomy: What the Radiologist Should KnowRadioGraphics2022Volume: 42Issue: 2pp. 321-339See More RSNA Education Exhibits Review of Breast Anatomy - Normal Variants and Expected Physiologic Changes in the BreastDigital Posters2022Contrast-Enhanced Mammography: Current Indications and Future Directions Â Digital Posters2019A Comprehensive Look at Disparities in Breast Cancer in the Non-Hispanic Black, Hispanic, and Transgender Community and What Policy Changes Should be ConsideredDigital Posters2022 RSNA Case Collection Invasive ductal carcinoma as developing asymmetryRSNA Case Collection2021Invasive ductal carcinoma of the breastRSNA Case Collection2020Pseudoangiomatous stromal hyperplasia - BI-RADS 4RSNA Case Collection2021 Vol. 39, No. 3 Slide PresentationAbbreviations Abbreviations: CC craniocaudal MLO mediolateral oblique Metrics Altmetric Score PDF download