乳腺X线检查漏诊乳腺癌的原因及避免方法

Why can breast carcinoma be missed and how to avoid

目的：研究并发现乳腺X线检查漏诊乳腺癌的原因,并找寻相关克服这些因素的方法,从而得到最适宜判读的乳腺X线片以及如何改进提高放射科医生的判读能力。方法：回顾分析了2008年1月~2009年1月共52例最初乳腺X线检查时漏诊而组织病理学证实为乳腺癌的病例,这些病例均做过钼靶、辅助超声、磁共振检查,且所有的病例都有细针抽吸活组织检查、针刺细切活检或切开活组织检查的组织病理学证实。结果：52例病理标本结果是36例浸润性导管癌,2例小叶导管癌,4例粘液性癌、4例炎性乳癌及3例导管原位癌,2例导管内乳头状癌和1例伴随乳头Paget病。分析这些癌误诊的原因,我们将其归为4类;患者、肿块,技术和读片者因素。肿块因素是是最常见的,占44.2%,而读片者因素是最少见的,占14.5%。32例癌是由有经验的放射科医生重复读片发现的,11例被建议进行点压放大摄影。52例患者（100%）都进行了MRI检查,其发现病灶的敏感性高于钼靶检查,但这只是对42例有诊断价值,其他的10例,仍需要进一步的穿刺活组织检查。结论：乳腺X线摄片漏诊乳腺癌的主要原因有以下4种：①患者因素（先天或后天的致密型乳腺）;②肿块因素（隐蔽性乳癌,多灶性或多中心性癌）;③技术因素（较差的曝光因素,乳腺位置不正和较差的后处理过程）;④读片者因素（感知力较差或误解）。

Objective：The aim of this study is to investigate the factors hindering early breast cancer detection and to outline the major guidelines to overcome these factors aiming to an optimum mammographic examination and interpretation by radiologists.Methods：We included 52 histopathologically proven breast carcinomas that were initially missed on mammography.The cases were subjected to mammography,complementary US,MRI and digital mammography in some cases and all cases were histopathologically proven either by FNAB,CNB or open biopsy.Results：Revision of the pathological specimens of these 52 cases revealed 36 infiltrating ductal carcinomas,2 lobular,4 mucinous,4 inflammatory carcinomas,3 carcinomas in situ,2 intraductal papillary carcinomas and 1 case with Paget disease of the nipple.In analyzing the causes responsible for misdiagnosis of these carcinomas we classified them into 4 causative factors;patient,tumor,technical or provider factors.Tumor factors were the most commonly encountered,accounting for 44.2%,while provider factors were the least commonly encountered in 15.3%.32 carcinomas were detected on double and re-reading by more experienced radiologists.Additional mammographic views were recommended in 11 cases.Complementary MRI examination was performed for all 52 cases（100%） and showed a higher sensitivity than mammography in carcinoma detection.Conclusion：Four main factors are responsible for missing a carcinoma： ① Patient factors（inherently dense breasts or acquired dense breasts）;② Tumor factors（subtle carcinoma,masked carcinoma,multifocal carcinoma and multicentric carcinoma）;③ Technical factors（bad exposure factors,malpositioned breasts and bad processing quality）;④ Provider factors（bad perception and misinterpretation）.