Radiology Teaching Files > Case 61795140

Last visited 09/12/2012 Breast Mass
Contributed by: Teresa Finnila, Resident, SAMMC, Texas, USA.
Patient: 51 year old
History: 51 y/o female presents with a new palpable breast mass. Last screening mammogram 10 months earlier was benign.

Fig. 1: CC view. 7/31/2012.

Fig. 2: MLO view. 7/31/2012.

Fig. 3: Comparison: Left MLO 11/2/2011

Fig. 4: Comparison (3 years prior): Left MLO 11/6/2009.

Fig. 5: Spot MLO. 7/31/2012.

Fig. 6

Fig. 7

Fig. 8

Fig. 9

Mammographic findings: There is a palpable marker in the upper outer quadrant of the left breast, without discrete underlying mass or asymmetry. On compression MLO view, this area demonstrates dispersion, although there are persistent fibroglandular densities on CC spot compression view. The examination otherwise demonstrates no suspicious masses or microcalcifications, architectural distortion, axillary adenopathy, skin thickening, or nipple retraction. Given the palpable complaint, further evaluation ultrasound was performed.

Sonographic findings: Targeted sonographic evaluation of this region demonstrates an irregular hypoechoic mass with angular margins, with posterior shadowing, measuring 24 x 14 x 12 mm.  This mass is located in the 2 o'clock position, 8 cm from the nipple, and corresponds to the palpable area of concern. Color flow Doppler evaluation is significant for internal vascular flow.  In the left axilla a reniform shaped lymph node with echogenic hilum is present, with a slightly irregular cortex, measuring 3 mm in maximal thickness.

Bi-RADS 5, Highly Suggestive of Malignancy.

Diagnosis: Invasive ductal carcinoma NOS with metastatic deposit in the left axillary lymph node.  Areas of high-grade (grade III) DCIS were also present.

Mammographically occult cancers may be missed due to many factors, which can be broken down into the following categories: breast tissue characteristics, imaging quality, or perceptual errors. Dense breast tissue is known to obscure focal aymmetry or small mass detection. Likewise, a slowly growing carcinoma may be difficult to detect if a sufficient interval comparison is not available. Typically at least a 2-year comparison is recommended. Technically, if poor patient positioning is not remedied, a lesion may not even be in the field of view, or may be missed due to lack of ability to directly compare to a prior study. Perceptually, the radiologist may not spot the relevant finding, or may erroneously dismiss a subtle finding.

Depending on the study cited, up to 10-35% of breast cancers may be missed on mammography. In one study of Japanese women, the addition of screening ultrasound to mammography increased the detection of mammographically occult cancers by 15%. In this case, ultrasound allowed appropriate Bi-Rads categorization of this patient, which lead to the correct management and diagnosis.


Uchida et al. Breast Cancer. 2008;15(2):165-8. Epub 2008 Jan 26.

Missed Breast Carcinoma: Pitfalls and Pearls. July 2003 RadioGraphics, 23, 881-895.

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Additional Details:

Case Number: 61795140Last Updated: 2012-09-12
Anatomy: Breast   Pathology: Neoplasm
Modality: Other, USAccess Level: Readable by all users

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