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Background and purpose: Recent metanalyses indicate high diagnostic performance for contrast enhanced mammography (CEM), with sensitivity >90%. We reviewed cancer cases examined with CEM to identify false negative results and possible causes. Methods: 516 patients underwent CEM over 5 months at a single clinic with 22 cases of malignancy diagnosed. The mammographic images, CEM technique, tumour size and histology were reviewed for those with no abnormal CEM enhancement. Results: Review identified 4 false negative cases. CEM technique and mammographic positioning were adequate for all, but in 1 case the region of interest was deep and not included on the CC view, and in 1 case the malignancy was mammographically occult. While invasive carcinoma was present in all cases, the disease was predominantly in situ in 2 cases.Tabled 1Patient Age Menopausal StatusBreast DensityOther RisksBackground ParenchymalEnhancement2D/3D FindingsHistology41PreDNilMinimal9mm calcifications & NSD***3mm IC NST* grade 29mm DCIS ING**47PreCNilMarked40mm calcs1.2mm IC NST* grade 22mm Tubular gd140mm DCIS HNG**59PostDStrong family history AshkenaziMarked15mm NSD*** containing fine calcifications16mm IC NST* grade 3DCIS HNG**49PostCNilModerateNil8mm IC NST* grade 2DCIS ING***invasive carcinoma no special type**ductal carcinoma in situ intermediate / high nuclear grade ***non-specific density Open table in a new tab *invasive carcinoma no special type**ductal carcinoma in situ intermediate / high nuclear grade ***non-specific density Conclusions: No reason for false negativity was identified although minimal tumour angiogenesis is presumed to be an explanation. Careful correlation of clinical and mammographic 2D/3D findings helps to avoid missed cancers. References: 1. Contrast-Enhanced Mammography versus Breast Magnetic Resonance Imaging: A Systematic Review and Meta-Analysis 2. Fabrizia Gelardi 1,2, Elisa Maria Ragaini 1 , Martina Sollini 1,2,*, Daniela Bernardi 1,2 and Arturo Chiti 1,2 Diagnostics 2022, 12, 1890. https://doi.org/10.3390/diagnostics12081890 3. Contrast-enhanced Mammography versus Contrast enhanced Breast MRI: A Systematic Review and Meta-Analysis 4. Nina Pötsch, MD • Giulia Vatteroni, MD1 • Paola Clauser, PhD • Thomas H. Helbich, MD • Pascal A. T. Baltzer, MD 5. Radiology 2022; 305:94–103 • https://doi.org/10.1148/radiol.21253