Ultrasonographic findings of missed breast cancer: pitfalls and pearls

Breast ultrasonography (US) is an indispensable tool for diagnosis of palpable and non-palpable breast masses and can facilitate good patient care for breast cancer. However, it is of limited value in cases of isoechoic lesions surrounded by fat, heterogeneous echoic lesions surrounded by a heterogeneous background, deep lesions in huge breasts, subareolar lesions, and lesions caused by poor and underdeveloped operator skills. Some breast tumors such as ductal carcinoma in situ and invasive lobular carcinoma are easily missed on US because of the nature of the lesions. Recent studies have emphasized the use of tools complementary to B-mode US, including real-time elastography and Doppler imaging, in the evaluation of breast lesions missed on US. Radiologists can take a number of steps that will enhance the accuracy of US image interpretation and decrease the rate of false-negative findings. These steps include reviewing clinicopathological data, using mammography and MRI to help assess breast lesions missed on US, strictly adhering to positioning and technical requirements, being alert to subtle features of missed breast lesions, and judging a lesion by its most malignant feature.