Mammographic Characteristics of 115 Missed Cancers Later Detected with Screening Mammography and the Potential Utility of Computer-aided Detection1
Robyn L. Birdwell, MD,
Debra M. Ikeda, MD,
Kathryn F. O’Shaughnessy, PhD and
Edward A. Sickles, MD
1 From the Department of Radiology (H-1307), Stanford University Medical Center, 300 Pasteur Dr, Stanford, CA 94305-5105 (R.L.B., D.M.I.); R2 Technology, Inc, Los Altos, Calif (K.F.O.); and the Department of Radiology, University of California, San Francisco (E.A.S.). From the 1999 RSNA scientific assembly. Received February 25, 2000; revision requested April 9; revision received August 14; accepted September 6. Address correspondence to R.L.B. (e-mail: birdwell@leland.stanford.edu).
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Figure 1a. Screening mammograms in a 63-year-old woman demonstrate breasts composed mostly of fat and were prospectively interpreted as negative. Cancer was detected in the right breast at the 6-o’clock position on the next scheduled screening mammogram 14 months later. (a, b) At the 6-o’clock position in the right breast are branching pleomorphic calcifications (arrow). Reasons for possible miss include the location of the lesion at the edge of the breast on the mediolateral oblique (MLO) view and distracting lesions elsewhere in the breasts. (c) Photographic enlargement of the standard craniocaudal (CC) view demonstrates morphology of the calcifications as branching and pleomorphic. (d) CAD images of the digitized mammograms show marks generated by the computer algorithm. The calcifications are marked with a triangle on both the CC and MLO views. There also is one false-positive CAD mark on benign calcifications in each of the four views.
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Figure 1b. Screening mammograms in a 63-year-old woman demonstrate breasts composed mostly of fat and were prospectively interpreted as negative. Cancer was detected in the right breast at the 6-o’clock position on the next scheduled screening mammogram 14 months later. (a, b) At the 6-o’clock position in the right breast are branching pleomorphic calcifications (arrow). Reasons for possible miss include the location of the lesion at the edge of the breast on the mediolateral oblique (MLO) view and distracting lesions elsewhere in the breasts. (c) Photographic enlargement of the standard craniocaudal (CC) view demonstrates morphology of the calcifications as branching and pleomorphic. (d) CAD images of the digitized mammograms show marks generated by the computer algorithm. The calcifications are marked with a triangle on both the CC and MLO views. There also is one false-positive CAD mark on benign calcifications in each of the four views.
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Figure 1c. Screening mammograms in a 63-year-old woman demonstrate breasts composed mostly of fat and were prospectively interpreted as negative. Cancer was detected in the right breast at the 6-o’clock position on the next scheduled screening mammogram 14 months later. (a, b) At the 6-o’clock position in the right breast are branching pleomorphic calcifications (arrow). Reasons for possible miss include the location of the lesion at the edge of the breast on the mediolateral oblique (MLO) view and distracting lesions elsewhere in the breasts. (c) Photographic enlargement of the standard craniocaudal (CC) view demonstrates morphology of the calcifications as branching and pleomorphic. (d) CAD images of the digitized mammograms show marks generated by the computer algorithm. The calcifications are marked with a triangle on both the CC and MLO views. There also is one false-positive CAD mark on benign calcifications in each of the four views.
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Figure 1d. Screening mammograms in a 63-year-old woman demonstrate breasts composed mostly of fat and were prospectively interpreted as negative. Cancer was detected in the right breast at the 6-o’clock position on the next scheduled screening mammogram 14 months later. (a, b) At the 6-o’clock position in the right breast are branching pleomorphic calcifications (arrow). Reasons for possible miss include the location of the lesion at the edge of the breast on the mediolateral oblique (MLO) view and distracting lesions elsewhere in the breasts. (c) Photographic enlargement of the standard craniocaudal (CC) view demonstrates morphology of the calcifications as branching and pleomorphic. (d) CAD images of the digitized mammograms show marks generated by the computer algorithm. The calcifications are marked with a triangle on both the CC and MLO views. There also is one false-positive CAD mark on benign calcifications in each of the four views.
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Figure 2a. Screening mammograms in a 72-year-old woman demonstrate fatty breasts and were originally interpreted as negative. Cancer was detected in the upper outer portion of the right breast on the following scheduled screening mammogram 13 months later. (a) CC and (b) MLO views demonstrate a 7-mm mass (arrow) similar in density to the residual glandular tissue in the upper outer quadrant of the right breast. Reasons for possible miss include lucent areas within the mass and possible obscuration by an overlying vessel on the MLO view. CAD (not shown) did not mark this small low-density spiculated lesion.
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Figure 2b. Screening mammograms in a 72-year-old woman demonstrate fatty breasts and were originally interpreted as negative. Cancer was detected in the upper outer portion of the right breast on the following scheduled screening mammogram 13 months later. (a) CC and (b) MLO views demonstrate a 7-mm mass (arrow) similar in density to the residual glandular tissue in the upper outer quadrant of the right breast. Reasons for possible miss include lucent areas within the mass and possible obscuration by an overlying vessel on the MLO view. CAD (not shown) did not mark this small low-density spiculated lesion.
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Figure 3a. Screening mammograms in an 85-year-old woman with large fatty breasts show bilateral calcified vessels. These technically suboptimal screening mammograms were interpreted as negative. Cancer was detected in the right upper outer quadrant on the next scheduled screening mammogram 12 months later. (a) CC and (b) MLO views show deficiencies in mammographic technique on all but the right CC view. The anterior aspect of the breast was not included on the right breast MLO view or the left breast CC view. No pectoral muscle is included in the image field on the left MLO view. A prominent skin fold in the left CC view indicates poor breast compression. None of these technical factors were judged to have affected the detection of the extensive pleomorphic calcifications in the upper outer portion of the right breast (arrows). (c) Regional pleomorphic calcifications occupy a 5-cm area on this photographic enlargement of the right MLO view. (d) CAD marked the large area of calcifications in both CC and MLO views in several locations in the right upper outer quadrant. Each of the four views also has one false-positive mark over arterial calcifications. Specifically, the most lateral mark on the right CC view and the most inferior mark on the MLO view are false-positive.
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Figure 3b. Screening mammograms in an 85-year-old woman with large fatty breasts show bilateral calcified vessels. These technically suboptimal screening mammograms were interpreted as negative. Cancer was detected in the right upper outer quadrant on the next scheduled screening mammogram 12 months later. (a) CC and (b) MLO views show deficiencies in mammographic technique on all but the right CC view. The anterior aspect of the breast was not included on the right breast MLO view or the left breast CC view. No pectoral muscle is included in the image field on the left MLO view. A prominent skin fold in the left CC view indicates poor breast compression. None of these technical factors were judged to have affected the detection of the extensive pleomorphic calcifications in the upper outer portion of the right breast (arrows). (c) Regional pleomorphic calcifications occupy a 5-cm area on this photographic enlargement of the right MLO view. (d) CAD marked the large area of calcifications in both CC and MLO views in several locations in the right upper outer quadrant. Each of the four views also has one false-positive mark over arterial calcifications. Specifically, the most lateral mark on the right CC view and the most inferior mark on the MLO view are false-positive.
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Figure 3c. Screening mammograms in an 85-year-old woman with large fatty breasts show bilateral calcified vessels. These technically suboptimal screening mammograms were interpreted as negative. Cancer was detected in the right upper outer quadrant on the next scheduled screening mammogram 12 months later. (a) CC and (b) MLO views show deficiencies in mammographic technique on all but the right CC view. The anterior aspect of the breast was not included on the right breast MLO view or the left breast CC view. No pectoral muscle is included in the image field on the left MLO view. A prominent skin fold in the left CC view indicates poor breast compression. None of these technical factors were judged to have affected the detection of the extensive pleomorphic calcifications in the upper outer portion of the right breast (arrows). (c) Regional pleomorphic calcifications occupy a 5-cm area on this photographic enlargement of the right MLO view. (d) CAD marked the large area of calcifications in both CC and MLO views in several locations in the right upper outer quadrant. Each of the four views also has one false-positive mark over arterial calcifications. Specifically, the most lateral mark on the right CC view and the most inferior mark on the MLO view are false-positive.
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Figure 3d. Screening mammograms in an 85-year-old woman with large fatty breasts show bilateral calcified vessels. These technically suboptimal screening mammograms were interpreted as negative. Cancer was detected in the right upper outer quadrant on the next scheduled screening mammogram 12 months later. (a) CC and (b) MLO views show deficiencies in mammographic technique on all but the right CC view. The anterior aspect of the breast was not included on the right breast MLO view or the left breast CC view. No pectoral muscle is included in the image field on the left MLO view. A prominent skin fold in the left CC view indicates poor breast compression. None of these technical factors were judged to have affected the detection of the extensive pleomorphic calcifications in the upper outer portion of the right breast (arrows). (c) Regional pleomorphic calcifications occupy a 5-cm area on this photographic enlargement of the right MLO view. (d) CAD marked the large area of calcifications in both CC and MLO views in several locations in the right upper outer quadrant. Each of the four views also has one false-positive mark over arterial calcifications. Specifically, the most lateral mark on the right CC view and the most inferior mark on the MLO view are false-positive.
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Figure 4a. Bilateral screening mammograms in a 68-year-old woman with heterogeneously dense breast tissue were initially interpreted as negative. Two cancers, one in the upper inner and the other in the upper outer portion of the left breast, were detected on screening mammograms obtained 10 months later. (a, b) There is a spiculated dense mass (straight arrow) in the upper inner portion of the left breast. Reasons for possible miss include the location of the lesion at the chest wall, at the edge of the film, and at the edge of glandular tissue. This lesion is more obvious than the subtler spiculated mass in the upper outer quadrant (curved arrow). (c) CAD images show the more subtle spiculated lesion marked by an asterisk on the left CC view only. The denser spiculated lesion near the chest wall (not marked) presents an example of the lower sensitivity of CAD in the posterior portion of the breast. The asterisk in the right MLO view is a false-positive CAD mark in an area of benign-appearing breast density.
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Figure 4b. Bilateral screening mammograms in a 68-year-old woman with heterogeneously dense breast tissue were initially interpreted as negative. Two cancers, one in the upper inner and the other in the upper outer portion of the left breast, were detected on screening mammograms obtained 10 months later. (a, b) There is a spiculated dense mass (straight arrow) in the upper inner portion of the left breast. Reasons for possible miss include the location of the lesion at the chest wall, at the edge of the film, and at the edge of glandular tissue. This lesion is more obvious than the subtler spiculated mass in the upper outer quadrant (curved arrow). (c) CAD images show the more subtle spiculated lesion marked by an asterisk on the left CC view only. The denser spiculated lesion near the chest wall (not marked) presents an example of the lower sensitivity of CAD in the posterior portion of the breast. The asterisk in the right MLO view is a false-positive CAD mark in an area of benign-appearing breast density.
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Figure 4c. Bilateral screening mammograms in a 68-year-old woman with heterogeneously dense breast tissue were initially interpreted as negative. Two cancers, one in the upper inner and the other in the upper outer portion of the left breast, were detected on screening mammograms obtained 10 months later. (a, b) There is a spiculated dense mass (straight arrow) in the upper inner portion of the left breast. Reasons for possible miss include the location of the lesion at the chest wall, at the edge of the film, and at the edge of glandular tissue. This lesion is more obvious than the subtler spiculated mass in the upper outer quadrant (curved arrow). (c) CAD images show the more subtle spiculated lesion marked by an asterisk on the left CC view only. The denser spiculated lesion near the chest wall (not marked) presents an example of the lower sensitivity of CAD in the posterior portion of the breast. The asterisk in the right MLO view is a false-positive CAD mark in an area of benign-appearing breast density.
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Copyright © 2001 by the Radiological Society of North America.
