 So now what is a misdressed cancer? A misdressed cancer is really defined as per the quote from this article by Leslie Lamp and others. It is a malignancy that can be seen on a mammogram when you view it in isolation. You don't compare it with the current mammogram where you can actually see the cancer evidently because then you're biased but you see that blinded to the current findings and you can still pick up the mammogram. So that is a true missed cancer and about 35, up to 35% of cancers detected as interval cancers on screening can actually be classified as missed breast cancers when the prior studies are blinded and read. So that is a high number to be sure. So we have to decrease our mis-rate that has to be the aim of every breast imager. But at the same time when you're reviewing these mammograms, you must not sit in judgment either on others or on yourself because you must remember that you will miss cancers. Each one of you in breast imaging whether today or tomorrow is going to be missing cancers. The mistakes will come back to you. You will discover them and other people's mistakes will come to you. So don't ask how could he or she have missed that or how could I have missed that. That doesn't help you but try and grow. Say what can I learn from this case? How can I grow and avoid this mistake in the future? So that is what this talk is about to show you potential pitfalls as well as actual pits into which we've fallen and then learned something, innumerable ways of missing breast cancer. So how do I miss the, let me count the ways. This is a very busy slide. I'm not going to list all the types, all the ways of missing breast cancer. I like to divide them into three categories. One is technical factors, that is poor positioning, poor technique, poor contrast, dense sparenchyma, all these are technical factors. Then one is the nature of the disease. You can have very slow growing disease which doesn't show up as interval change on sequential mammograms or very subtle features of malignancy such as a very little bit of architectural distortion or margins that are just a little off like you saw in multiple cases shown by Shilpa and Halas talk and in the previous talks also. So suspicious but stable morphology, subtle findings and then you can have fixed thought processes that is on us that you can find one finding and ignore the rest of the mammogram satisfaction of search or you cannot be focused on your mammogram. So when you're reading the mammogram, you have to be absolutely focused in a dark, quiet room so that there's no inattention and no missing or findings, but yes, there's fatigue and then they can be fixed thought processes that she's had multiple mammograms across the years that are normal. So this one is also going to be normal. Let me copy paste the report and that's it. I'm done quickly with this normal mammogram. So these are thought processes that can lead to missing cancers. So how do we decrease the miss rate? Now there's certain areas on a mammogram that are more likely to have hidden findings and if you develop a good search pattern to cover all these areas carefully, you can decrease your miss rate. Now these images are from this lovely presentation by Monica Sheth and others that is available for free on the radiographics website and you should go through it. So one is the retroglandulofat that's a line drawn parallel to the pectoralis on the MLO view and this is also known as the Milky Way. Then there's the inner triangle on the CC view and the lower triangle on the MLO view, the retroareola region. No man's land is the retroglandulofat on the CC view and there should be no real extra tissue in this area and the anterior and the posterior fat fibroglondyglendular interface. So whenever you're reading a mammogram, if you have a mental checklist, have I seen this? Yes, have I seen this? Yes. Then you are less likely to find or less likely to miss things in these areas where findings can be hidden and edge of images and skin are also very important. So now let's go over to the cases and see what we can miss and how can we miss it? This is a 52 year old female who came in for a screening mammogram. So remember the retroglandulofat. So here's the no man's land. Now the breast tissue, the fibroglandulofat tissue should ebb like the tide, as Dr. Comstock told us in a mammography workshop some time ago. So it should get lesser and lesser as you're going away from the nipple. So it's already finished here. And then we have this little bump of tissue, a focal asymmetry there. So we are worried about this. Now I have a tomo and I can see immediately that it is a speculated, irregular, suspicious mass and this needs evaluation. If you don't have tomosynthesis, you can still do a spot on this, a spot magnification view and look at this in a very focused manner, this deep central area on ultrasound and you will pick up the finding. So this is a potential pitfall which you should try and avoid. Then always also look at the other side. This is a 54 year old female who complained of a right breast lump into two months. That is the mass and you are seeing a global asymmetry in this entire breast. There's skin thickening, there's nipple retraction, there's trabecular coarsening. So all these are very suspicious finding. There's also an axillary node there. But what do we see on the other side? You see this little bit of tissue peeking out. So if you're only focused on this, you're going to miss that. And there's going to be, if you're focused on this side, there's satisfaction of search, you'll miss this. We didn't, we pulled in the tissue and found another little cancer in the inframammary fold, which the patient couldn't palpate at all. So this is a very suspicious mass. It's got microbialated margins and spicules also. So you have to look at all corners. And a cardinal rule of mammography is never given to your clinician and say, I will, if the patient has a right breast lump, I will do only a right mammogram. No, you have to image both sides if she has both breasts. You cannot make do with doing only one-sided mammograms. Then this is a 46-year-old female who complained of left breast pain into 15 days. So retroglandular fat seems clear. Fat fibro-glandular interface seems clear. The lower triangle here, the medial triangles all look fine. The retro-irular regions look fine on the right, really. On the left on the MLO, it looks fine. But on the CC, you see subtle architectural distortion there. Now you can go for a spot and an ultrasound. I have tomos, so I first look at that. And I see a high density irregular mass with speculated margins here. So obviously suspicious and that's also axillary adenopathy. She couldn't palpate this. All she had was the pain, but we look at on ultrasound. And this is a very suspicious mass, of course. You have micro-logulated margins as well as speculated margins. Some echogenic specs suggest of microcalcifications, hypervascularity, metastatic lymph adenopathy. And this was an invasive ductal carcinoma. So always beware the retro-irular regions and look at them carefully, because these are missable on ultrasound also. When you're doing the nipple-irular complex, unless you put your probe carefully on that and angle in all directions, you can miss small masses there. So look at your MMO, do your ultrasound carefully when you're evaluating retro-irular regions. Then this is a 40-year-old patient who complained of a right breast lump into 10 days. Now you see that axillary node? Is it an axillary node? When we look at the other image, we see this little thing peeking out here and you see there. So this is actually a 12 to one o'clock mass. So edge of film findings are important, not only to not miss cancers, also to localize your mass, especially if it's not palpable. This one, however, was palpable and we had it on our clinical history sheet there. So this was a one o'clock mass. And on ultrasound, we called it very suspicious by that's four C mass, because we had a micro-lobulated heterogeneous mass, even though there's good through transmission. Shilpa told you about these malignancies that they are not, I mean, good through transmission has nothing to say to anything. So this was operated by the surgeon, by a palpation. Now, we are ably sometimes assisted in our goof ups by our clinical colleagues. We did say once weekly that maybe this should be localized. It's only a one centimeter mass. And you must remember that something that's palpable in the OPD when the patient is under anesthesia and the muscles are all relaxed may not be palpable in the OT. So you have to be strong about your protocols that no surgeon, no dear surgeon, this is a very tiny mass and I must localize it for you because you may not find it in the OT. So that is not really on us, but I just wanted to show you that you do have to stand up for your protocols. Another thing, rat path concordance, Aman is going to be talking about it. So the pathology was fibrocystic changes and this surgeon did not route the patient back through us. So the patient has to come back to you as a radiologist so that you can call this is it okay or is it not okay? So this was fibrocystic changes and the patient went away because the surgeon said all is good and you can go away. But one year later, she was back with a mask. She said, surgeon, you operated this but now it is double the size. And now you can see it's peeking out more from the edge of the film and there's also this leucency here. What is that leucency? So when we looked at it on ultrasound, the mass of course has become one and a half times in size. It's 1.8 centimeters. And also the surgeon has gone in beautifully right next to it and missed the cancer altogether. But look at how close this area of fat necrosis which is giving you that leucency is. So stand up for your protocols, do what's correct and less cancers get missed but the surgeon wouldn't listen and still went in under palpation. And this time he got the cancer, it was a musinus cancer but he left positive margins. This patient eventually went to a mastectomy which is unforgivable because musinus cancers can have very good outcomes and you, I mean like this was not a greatly handled case. Now, not everything that looks renaiform and has something that looks like a fatty hyalum in the breast, not everything is an intramammary node. This was a new mass and I should have known better but I didn't. I did call it a new mass and gave it a three instead of a two. But this wonderful renaiform structure and the leucency in the center plus this strand that to me I thought it might be a vessel made me call this likely an intramammary node. I did ask for an MR but MR also they said it's T2 bright, all is good. This is a benign finding. However, this grew and this was eventually proven to be a musinus carcinoma. So new masses have to be worried about even if they look very benign. You have to be very, you have to handle them very, very carefully. Then this is a 53 year old female and this case shows you many ways of missing breast cancer. Now this, you see how dense the breasts are. She was very regular with her mammograms or extremely, extremely regular and she presented with a right breast lump in November 2019. So that's a very dense breast and this is her 2018 mammogram on the outside and we thought we could see the mass kind of here and on ultrasound, wow, it's a simple system. We are extremely happy. We are targeting that simple system. We are thrilled that her only finding is a simple system. Last year the mammogram was normal. So the palpable concern is a simple system. Please go home, don't worry. And remember this was November 2019 and in March 2020 we went into lockdown. So her next mammogram was only November 2021. And now you see this left breast cancer right here, lower in a quadrant eight o'clock here. See that? Look at the mammogram nicely and that's the tomosynthesis. The eight o'clock thing and a very subtle area of architectural distortion here. I've focused it on that slide, but this is a plus minus for me. It may not actually be missed because when you are scrolling through the tomo, it just kind of flips through on one slice. So subtle architectural distortion can be a reason for missing cancers. Okay, so then of course we were very worried about this and like feeling very bad that we've missed this. So we asked for an MR also and that's the MR and you can see there's the left breast and the cancer and then on the right another cancer. Yes, there's indeed another cancer. So shall we go back to the tomo now? When you look at the tomo, you realize there's additional tissue here. How many of you saw that on the screen? Clearly not. This is of course a very quick presentation. So you're not going to be able to see that, but we didn't actually focus on this because we were so focused on kicking ourselves, judging ourselves and looking at this cancer on the left, eight o'clock location. So, but we did see it on ultrasound fortunately and of course on MR. So there it is on ultrasound, the right breast cancer, both were invasive ductile, a higher grade on the left, a lower grade on the right, but fortunately both no negative. So no negativity is the most important factor in prognostication. So this lady still had the possibility of a decent outcome, but look at the reasons why we missed it. First of all, very dense breasts, then lower inner quadrant, subtle architectural distortion, technical factors also. Now the nipple always points towards the side where you are going to be missing breast tissue. So this nipple is pointing this side. I've missed a lot of breast tissue here. My tech has missed a lot of breast tissue here, but it's my call. I should have asked for a repeat view. It's not the tech's fault. She's given the view. I can always ask for a repeat and I should have. And because it was a single view finding, I ignored it. If at all I saw it, inattention, dense tissue, technical factors. I also had satisfaction of search even the second time. So many reasons for missing breast cancer. You have to be very careful. Then this is a 54 year old lady who came to us just last week. She had a left breast lump into three months and you can hardly see it. There's just a little bit of architectural distortion there. But on the right, there is very subtle microcalcification. Now if you're again focused on the left breast only and you're not going to be looking at both breasts with your magnifier or magnifying glass, then you're going to be missing these subtle breast cancers. So always be very careful and look at your subtle microcalcs very carefully because the left was an invasive ductile, but you're going to be missing the DCIS on this side because like you have been taught in Dr. Rupa's talk, the distribution as well as the fine pliomorphic, fine branching nature, these are all suspicious and need to go to biopsy. Then this is a 60 year old lady who comes in for a screening and we see this which is an involuted fibroadenoma with all that popcorn type calcification and another mass which also I suppose is a fibroadenoma or is it, remember that one mass being a fibroadenoma does not make all other masses fibroadenoma. So look at the features. You have indistinct margins, your high density. It's suspicious. Definitely look at all those micro lobulations and on ultrasound also very suspicious. It's heterogeneous. It's irregular in shape. There's a lot of hypervascularity. So this we took to biopsy and this was solid papillary DCIS. So do not assume anything in your breast imaging. Do not have fixed thought processes. Then this is a lady, a quick case, 33 years old and she had very young and at 29, she had a right breast conservative surgery for an invasive ductile carcinoma and we were doing regular follow-ups. 2017, we thought there was AD. We were following six month follow-ups here and at 2019, a colleague said that the AD has increased and I reviewed and said, yes, the AD has increased and we are going to do a vial. We put in a vial, not very well, but it was deceptible and this came out and it was benign. So we were happy. The patient was happy, no cancer there and she went home. But what do we find in 2020? We find that there is a big mass there. Now look again. We were so focused on this that we did not see the developing asymmetry in that area. And on tomosynthesis, I actually passed the developing asymmetry because I thought that it's kind of opened up on the oblique although it doesn't look so good on the CC. So no assumptions, no fixed thought processes, single view findings are important. And sadly, she had an MR also at that point at which we said that the AD has increased and there was some suspicious enhancement there that was called, but this first pass, just larger than a focus finding was missed. So this was on the first pass MIP also but not on the second and third. So this got missed on both MR and tomosynthesis and mammography. And of course, we didn't do a very good ultrasound of that area where we may not have picked it up in any case. So this is the large cancer. Shilpa, I'm just going to take a minute or so more. I'm sorry. And this, so remember that change is important but no change is also not to be, clearly you should not allow yourself to fall into, be very complacent if there is no change. So this was reported from outside as a stable finding by RADS1 because there were four prior mammograms which were all stable. We saw this and we said, even though it's stable it's suspicious because it's irregular with speculated margins and suspicious on ultrasound also. So remember that irregular morphology trumps stability. And if you have a suspicious finding, you must biopsy unless you already have a pathology on it that it's benign and this was an adenoid cystic carcinoma and young patients, Shilpa has already covered. So young patient with stable findings that look like fibroadenoma still go to mammograms if they're between 30 and 40 because we have a lot of cancer between 30 and 40. And this one was a poking out mass from the fat-fibroglandular interface with microcalcification. So very suspicious and this was invasive ductile. And even under 30 suspicious finding this patient had two ultrasounds reported as benign. We found microcalc and ductile non-mass tissue and you find suspicious microcalc on mammography and this is suspicious. So similarly you can have false positives, microlobulated margins, pyrrexia of unknown origin picked up on CT, thought to be cause for the P.U.O. The malignant, everyone says this is malignant. We biopsy, it's T2, right? So already burnt our fingers with myosinus C.A. And biopsy, fibroadenoma, we don't believe it. We biopsy again, while we are waiting for the second biopsy P.U.O. cause comes out as brucellosis. And remember that all lymphedema is not inflammatory cancer. This is a patient that looks like inflammatory but many other causes that was tuberculosis and this is her insupposite inflammatory breast cancer resolving on ATT. And IgM venu has covered extensively. Second peak perimenopausalis speculated margins do not always mean a cancer. And you see that there is some fat density there. So this was called a 4C biocalate but this was IgM and even ultrasound findings were suspicious but IgM. So thank you and remember that there are many errors in breast imaging, but if you're careful you can totally, totally eliminate, not totally eliminate. I mean, you're still going to miss cancer you're still going to call some false positives but you can decrease your rate of misses and false positives. So it is natural to have some errors but it is good to be humble and compassionate towards others who have missed and it is good to progress by collecting those errors. Thank you so much.