1) Interval cancers occur between mammography screenings and can be missed due to limitations in mammography detection or characterization. The rate of missed interval cancers is reported between 7.5 to 22 per 10,000 mammograms. 2) Factors that can contribute to missed cancers include breast density, small lesion size, subtle appearance, and improper characterization. Retrospective reviews often find lesions that were visible but not properly characterized on prior mammograms. 3) Newer digital mammography techniques like digital breast tomosynthesis have been shown to improve detection and characterization compared to full field digital mammography alone, especially for women under 50 and those with dense breasts. Larger studies are still needed to fully evaluate performance.

1. Missed breast cancers
How to manage…
Thierry Pousse
HANOI 2015

2. ¨ Interval cancer: occured after mammography
before next MMG 7,5/10000 to 22/10000
¡ no abnormality/MMG even looking back
¡ False negative : missed detection or caracterisation
on prior MMG
172 lesions /427 MMG: visible but not specific
Birdwell Ikeda al Radiology al 2001:219;192-202 2003;226:494-503

3. ¨ False negative interval cancer
¨ False negative with very poor signal
¨ Occult cancers
¨ True interval cancer

4. ¨ Conditions
¡ « double » blind
¡ among normal MMG (%? )
¡ false positive (%?)
¡ Seniors or juniors (L1 ? L2?)
¨ Retrospective second look
¨ Difference between:
¡ K really visible but with non specific signs present
¡ K that could not be proved as pathologic

5. ¨ Subtle lesions: architecture break, density asymetry
¨ Tricky spots: prepectoral, retrogland, retroareolar, crease
under the breast
¨ Associated to evident lesion
¨ No stroma reaction or fibrous retraction
« Le seuil pour décider….est guidé par l’expérience et ne répond à aucune règle absolue. La seule certitude est qu’il faut
compléter les investigations jusqu’à ce que l’on ait obtenu un degré de certitude suffisant »
J Stinès. Les cancers du sein: les images visibles sur une seule incidence. J Radiol 2004; 85: 2083-94

9. Left centro mammal focal area density ?

10. L1/L2: ACR2
AND YOU?
2006 Diag was not possible
But 2008 :
focal density in forbidden TABAR
area !!

11. MILKY WAY

12. NO MAN’S LAND

13. INTERNAL QUADRANTS

15. Beware of focal area of
density in Tabar zones!
Clinical examination!!

17. Beware of Retro areolar area!

18. Little asymetric area of focal
density
only visible on one shot
Little round lump, not so dense
contoured microlobed
changing scale: mucinous K
Abnormality visible on only one shot
22% missed breast cancer (Ikeda)

19. Palpable mass left
QSE
Bird, Radiology
2001;219:192-202

20. Satisfaction of search!
Discovering abnormality → less rigorous analysis of the rest of the
parenchyma

22. ¨ unchanged lesions
- microcalcifications→ 63 months LevToaf Radiology 1994
- lumps → 54 months Meyer AJR 1981
¨ Opacity benin-like
5% tumors → 6.3 years Vx2 according to Weedon Fekiger Breast
Cancer Research 2008
¨ Microcalcifications benin-like

23. ¨ Cluster of benin microcalcifications will change
¨ 25% cluster of malignant microcalcifications
stable between 6-60 months
¨ 9% microcalcifications stable 2 years CCIS high
grade Lev Toaf Radiology 1994

24. Sparse linear microcalcifications / one shot only
Incomplete record
Miscaracterisation : ACR 2

25. Detection + Caracterisation
Zoom Face Profil
ACR5

26. ¨ Benin like microcalcifications
¨ Heterogeneous distribution of fibroconjonctive
tissue

30. Misdetection
Or very low signal ?

32. 1 YEAR LATER

34. ¨ K non visible/ MMG when diagnostic done
even looking back
¡ Clinical examination+++
¡ Causes conventionnally cited
ú Density of breast tissue
ú Size and topography of the lesion
ú Presence of CLI
Incidence * 5%K SIM study
**7% k retrospective study 1757 K
***24% high risk cancer patients
*SIM Study CHU Lapeyronnie Montpellier¨Pr TAOUREL 2010
**Foxcroft LM and al. Breast cancers invisible on mammography. Aust N Z J Surg 2000 ; 70 : 162-7.
***Morris EA and al. MRI of occult breast carcinoma in a high-risk population. AJR 2003 ; 181 : 619-26

35. 62years old /ATCD = 0
Clinical exam: swelling
QIE G
TYPE II

37. CCI grade I SBR 10mm

38. 71 years old ATCD =0
clinical exam normal
TYPE I

40. Colloidal carcinoma SBRII 22mm

41. 47 years old /ATC 2°degre
Autopalpation : lump right QSE
TYPE IV

43. CCI SBR III 45 mm

44. ¨ CLI : no distortion , minimal stroma reaction
¨ CCI: 50% >5 mm few distortion
CLI CCI

45. ¨ MMG negative even looking backyard but
MMG positive when diagnosis is done
¨ K +/ MMG but non visible and K developped
between 2 MMG
¨ K developed between 2 MMG
¡ Young women
¡ % CLI
¡ SBR
¡ Biological index tumoral proliferation
¡ RH -

46. DIGITAL
MAMMOGRAPHY TOMOSYNTHESIS
¨ Contrast resolution
¡ Microcalcifications
¡ < 50 years old
¡ breast density - Pisano NEJM 2005
¡ Architecture break Hambly AJR 2009
¨ Second line /selected
patients ACR 0,3,4,5
¡ true lesion
¡ caracterisation architecture break ,
masse, microcalcifications
¨ Breast cancer screening
program

49. ¨ Consecutive serie 158 patients recalled after
MMG/ bresast cancer screening program(recall
rate 6.6%-2.4%) screening program conditions
¨ 21K:13%
¨ 137 negative
¨ TS performance
¡ 0 FN
¡ Negative 102/137 - : 75%
¨ It works for BIRADS 1-2 and BIRADS 3-4
Breast Cancer Res Treatment 2012, projet TOMMY

50. ¨ Single institutionnal retrospective reader study
¨ Data enriched- increasing number combination
of FFDM and DBT of cases BIRADS 3
¨ Study including combination of FFDM and
DBT images
Radiology:volume276;number1_july2015-65-72

51. ¨ The availability of prior FFDM and DBT
images during interpretation is a largely
independent contributing factor leading to a
reduction in the frequency of recommandations
to recall a woman without cancer for diagnostic
work up
¨ The avaibility of DBT had a larger effect on
radiologists performance levels than did the
avaibility of prior FFDM images

52. ¨ Publication and analysis of norwegian study
¨ Quality control
¨ 2D reconstruction from the 3D acquisition
¨ Diffusion of the technique to other companies
¨ Creativity of scientific community

53. ¨ Frequency
¨ Mistakes : detection , caracterisation
¨ Performance improvement
¨ Technical parameters
¨ Subtles images
¨ Conditions of reading mammography
¨ CAD, Second reading
Majid AS, de Paredes ES, Doherty RD et al. Missed breast carcinomas: pitfalls and peals. Radiographics 2003;23:881-95
« For a lawyer, lawsuits are a way of life.For a physician, it strikes at the core of our being Kopans D.
Mammography screening is saving thousands of lives, but will it survive medical malpractice? Radiology 2004; 230:
20-4

54. Cent choses entendues ne valent pas une chose vue.
(Trăm điều nghe không bằng một điều thấy)
Cette présentation n aurait pas été possible sans l’aide de
Dr Martine BOISSERIE LACROIX Fondation Bergonié BORDEAUX
Dr Luc CEUGNART Fondation O . Lambret LILLE
Pr Patrice TAOUREL CHU Lapeyronnie MONTPELLIER