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Introduction: Due to the increasing use of dynamic breast MRI and the limited availability of MR-guided interventions, MRI-detected lesions usually undergo a second-look ultrasound (SLUS). We investigated the safety of a negative SLUS and a benign SLUS correlate in excluding malignant and high-risk lesions (B3) and evaluated criteria for the rate of detection on SLUS. Methods: In the retrospective analysis, all breast MRIs performed between 2011 and 2013 were screened for newly detected lesions. We analyzed the SLUS detection rate dependent on breast density, mass character, lesion size, and histology. We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a negative and benign SLUS for malignant lesions (B5) and lesions requiring surgical excision (including high-risk and B5 lesions). Results: We successfully correlated 110 of 397 lesions. The detection rate was significantly higher for mass than for non-mass lesions and correlated with lesion size for mass lesions only. Lesions without/with a benign SLUS correlate were more frequently benign (including B3) or required no further procedure (B2). The sensitivity of SLUS in the detection of B3 and B5 lesions was 58%, and 73% in the detection of B5 lesions. The NPV of a negative or benign SLUS for B3 and B5 lesions was 89%, and 96% for B5 lesions. Discussion: SLUS is a safe diagnostic tool for the management of MRI-detected lesions and can spare patients from undergoing invasive procedures.

Ultrasound, in its new point-of-care conception, has been called the stethoscope of the future. Goal-directed bedside ultrasound examination, performed by a healthcare provider to answer a specific diagnostic question or guide an invasive procedure, is currently revolutionizing medical practice. It is used by various specialties in multiple clinical contexts for procedural, diagnostic, and screening applications. Point-of-care ultrasound is also a strategic technique in clinical radiology; it brings the radiologist closer to the patient (in interaction and understanding) like interventional and angiography procedures and, as an integrative imaging modality, is a vital radiological tool for decision-making in many situations. In this commentary, we present our observations on the use of ultrasound, in a sincere appeal to refrain from omitting ultrasound as a diagnostic technique in this era of deep professional change, in which radiologists must return to being a true clinical semiologist.

Purpose To predict detection rates (DR) in second-look ultrasound of MRI-detected breast lesions by systematically combining clinical and anthropomorphic features. Methods A total of 104 suspicious breast-lesions, that were initially detected on breast MRI and underwent subsequent SLU from January 2013 through December 2013, were evaluated in this retrospective analysis. All images were reviewed by an experienced radiologist for this study. Both anthropomorphic, spatial and BI-RADS lesion features were recorded. Uni- and multivariate Classification and Regression Trees (CRT) statistics were used to predict SLU DR by these features. Results Among 104 MRI-detected lesions, 58 (55.8%) showed a correlate on SLU. In univariate analysis, homogeneous fatty or dense fibro-glandular-tissue-composition (FGT) as assessed by ultrasound, segmental non-mass-distribution pattern and small breast size as assessed by MRI were significantly associated with higher DR on SLU. The remaining BI-RADS features did not significantly affect SLU DR according to our data. The predictive model could stratify the likelihood of SLU correlates as high, intermediate and low according to FGT, lesion type, size and position. Conclusions By systematically combining the features FGT, lesion type, size and position, we could predict SLU DR of MRI-detected breast lesions. This may help to decide the preferable method for lesion biopsy or follow-up in clinical practice.

PurposeThe study sought to investigate the outcome of breast magnetic resonance–guided biopsies as a function of the indication for magnetic resonance imaging (MRI), the MRI features of the lesions, and the performance or not of a targeted second-look ultrasound (SLUS) prior breast MRI-guided biopsy.MethodsWe identified 158 women with MRI-detected breast lesions scheduled for MRI-guided biopsy (2007-2013). Patient demographics, performance of targeted SLUS, imaging characteristics, and subsequent pathology results were reviewed.ResultsThree biopsies were deferred, and 155 lesions were biopsied under MRI guidance (155 women; median age 55.14 years; range 27-80 years). Ninety-eight women underwent a SLUS prior to the MRI-guided biopsy (63%). Of the 155 biopsied lesions, 23 (15%) were malignant, 106 (68%) were benign, and 26 (17%) were high risk. Four of 15 surgically excised high-risk lesions were upgraded to malignancy (27%). Most of the biopsied lesions corresponded to non–mass-like enhancement (81%, 126 of 155) and most of the biopsies (52%, 81 of 155) were performed in a screening context. No demographic or MRI features were associated with malignancy. No differences were noted between the 2 subgroups (prior SLUS vs no prior SLUS) except for the presence of a synchronous carcinoma associated with a likelihood of targeted SLUS before MRI-guided biopsy ( P = .001).ConclusionA negative SLUS does not influence the pathology outcome of a suspicious lesion biopsied under MR guidance.

Contrast enhanced magnetic resonance imaging (CE-MRI) has acquired a central role in the field of diagnosis and evaluation of breast cancer due to its high sensitivity; on the other hand, MRI has shown a variable specificity because of the wide overlap between the imaging features of benign and malignant lesions. Therefore, when an additional breast lesion is identified at CE-MRI, a second look with targeted US is generally performed because it provides additional information to further characterise the target lesion and makes it possible to perform US-guided biopsies which are costless and more comfortable for patients compared with MRI-guided ones. Nevertheless, there is not always a correspondence between CE-MR findings and targeted US due to several factors including different operator’s experience and position of patients. A new technique has recently been developed in order to overcome these limitations: US with MR coregistration, which can synchronise a sonography image and the MR image with multiplanar reconstruction (MPR) of the same section in real time. The aim of our study is to review the literature concerning the second look performed with this emerging and promising technique, showing both advantages and limitations in comparison with conventional targeted US.

The term “second look” lesions in MRI refers to lesions detected by MRI that were not initially seen on mammography or ultrasound. The objectives of our study were to analyse the displacement of targets between MRI and ultrasound; to define discriminating BIRADS morphological criteria to predict benign or malignant character and better establish the indications of second look ultrasound and biopsy; and to analyse the agreement between ultrasound and MRI in terms of morphological criteria. A retrospective and monocentric review was performed of the records of consecutive patients with breast abnormalities (mass or non-mass) initially detected by MRI that were not initially seen on mammography or ultrasound. All patients with abnormalities found during the performance of second look ultrasound and biopsied were included in the study. All lesions were documented using the BIRADS lexicon for MRI and ultrasound. Of 100 included patients, 108 lesions were detected by MRI, found via second look ultrasound and biopsied between January 2008 and 2010. All of the included patients were followed-up for a variable period, from 2 to 5 years. Eighty-two upon 108 biopsied lesions (76%) were benign and 26/108 lesions (24%) were malignant. This study confirmed the switch from procubitus to decubitus essentially displaces the tumour in the antero-posterior direction. It showed that the risk factors were not reliable criteria for establishing an indication for second look ultrasound. This study also showed that circumscribed contours and a progressive enhancement curve (type I) for masses on MRI had the strongest negative predictive value of greater than 0.85. In ultrasound, the round or oval shape, circumscribed contours and the parallel orientation to the skin favoured benignity with a NPV of greater than 0.85. For masses, the study showed that the agreement in interpretation of the benign versus suspicious morphological criteria between the MRI and the ultrasound was very weak for the shape (Kappa=0.09) and weak for the contours (Kappa=0.23). Finally, the MRI overestimated the size of the targets compared to ultrasound (Student t-test, p=0.0001). The performance of second look ultrasound has to be performed after the detection of an abdnormality on MRI even for lesion classified BIRADS 3. The biopsy indications must be wide with insertion of a clip and a control MRI. Only this control allows to stop the investigation if the biopsied lesion is benign.

This study evaluated the usefulness of magnetic resonance (MR)-navigated ultrasound (US) for evaluation of magnetic resonance imaging (MRI)-detected lesions not visible on second-look US and analyzed differences in lesion-to-nipple distance between supine and prone positions. Of the 831 consecutive patients who were diagnosed with breast cancer and examined with breast MRI from June 2013 to September 2015, 40 lesions in 37 patients who underwent MR-navigated US for MRI-detected lesions that were not visible on second-look US were included. First, MRI was performed in a prone position using a 1.5-T imager, and second, MRI was performed in a supine position for MR-navigated US. Of 40 lesions, 31 (78%) were identified with MR-navigated US, whereas 5 (13%) lesions disappeared on supine MRI and 4 (10%) exhibited no correlation on MR-navigated US. Of 31 lesions with pathologic confirmation, 7 (23%) were malignant, 2 (6%) were high-risk lesions and 22 (71%) were benign lesions. Comparison of the US findings of benign and malignant lesions revealed that orientation of the lesion differed significantly (p = 0.045), whereas lesion shape, margin and echo pattern did not significantly differ between the two groups (p = 0.088, p = 0.094 and p = 0.412, respectively). Median difference in lesion-to-nipple distance on supine and prone MRI was 8 mm (0–34 mm) in the horizontal direction and 5 mm (0–39.5 mm) in the vertical direction. Thirteen lesions exhibited a >1-cm difference in both horizontal and vertical directions. In conclusion, MR-navigated US was useful for the evaluation of MRI-detected lesions that were not visible on second-look US in breast cancer patients.

To asses the value of second-look ultrasound (US) for identifying BIRADS 3 (Breast Imaging Reporting Data System) mammary lesions detected by breast Magnetic Resonance imaging (MRI).From April 2008 to May 2009 330 breast MRI were performed of which 60 patients are classified as BIRADS 3. 84 lesions underwent second-look US and percutaneous vacuum biopsy Vacora system US-guided.lesions were stratified into two groups: visible on US (Group 1) and not visible on US (Group 2). The clinical impact of second-look US was studied in terms of negative predictive value (NPV).The positive predictive value (PPV) of category 3 BIRADS MRI was found to be 89%. Second look-US results detected lesions in 51% of the MRI enhancing lesions. The second look-US showed a NPV of 97%. The NPV of second look-US was significantly greater than the NPV of MRI BIRADS 3 (97% vs 89%, p0.05). The logistic regression analysis showed a higher number of malignant lesions in group 1 than in group 2 (7vs 2, OR 3.7, p0.05).The second-look US permitted the correct management of subcentimetric MRI BIRADS 3 lesions not visible with conventional imaging tecniques.

This study prospectively assessed second-look ultrasound (US) for the evaluation of incidental enhancing lesions identified on preoperative breast magnetic resonance imaging (MRI).Between 2004 and 2007, 182 patients with malignant breast lesions detected on US and/or X-ray mammography and confirmed by cytology/histology underwent preoperative breast contrast-enhanced (CE)-MRI. Patients with incidental lesions on breast MRI underwent second-look high-resolution US directed at the site of the incidental finding. Diagnosis of incidental lesions was based on biopsy or 24-month follow-up.Breast MRI detected 55 additional lesions in 46/182 (25.2%) patients. Forty-two of 55 (76.3%) lesions were detected on second-look US in 38/46 (82.6%) patients. Malignancy was confirmed for 24/42 (57.1%) correlate lesions compared with 7/13 (53.8%) noncorrelate lesions. Second-look US depicted 8/9 (88.8%) Breast Imaging Reporting and Data System (BI-RADS) 5, 16/22 (72.7%) BI-RADS 4 and 18/24 (75%) BI-RADS 3 lesions. Sensitivity, specificity, accuracy and positive and negative predictive values for lesion detection/diagnosis was 100%, 88.9%, 94.6%, 90.3% and 100% for MRI and 64.3%, 70.4%, 67.3%, 69.2% and 65.5% for second-look US. Improved performance for US was obtained when masslike lesions only were considered.Second-look US is a confirmatory method for incidental findings on breast MRI, particularly for mass-like lesions.

MRI is widely accepted to be the most sensitive imaging modality for detecting breast cancer, but has relatively low specificity. Often additional enhancing areas are identified on MRI that require further investigation. In this study we evaluated second-look ultrasound following breast MRI and the impact of this on patient management.

Breast MRI is being increasingly used in breast cancer to look for extent of disease, in high-risk screening and in the dense breast. Frequently incidental lesions are detected on MRI that require second-look ultrasound or stereotactic biopsy. Incidental MRI-detected lesions may be occult on conventional imaging and require MRI-guided biopsy. We describe our experiences with US MRI fusion to try and reduce the need for MRI-guided biopsy.

Objective: The aim is to show ultrasound (US) findings of additional malignant lesions of breast carcinoma visualized on targeted second-look US that were not identified by mammography or US prior to the time of diagnosis. Materials and Methods: A double-blind retrospective review of the US results from January 2008 through August 2010 of 228 patients with known breast cancer was conducted by two expert radiologists. The focus of the review was on the second-look US characteristics (following BI-RADS criteria) of 26 documented additional malignant lesions of the 76 with successful sonographic correlation from the 123 lesions detected by magnetic resonance imaging (MRI). All of them, before the MRI, had an initial mammography and a US with a histopathological biopsy of the primary lesion. Results: Approximately 60 to 70% of the findings were classified as BI-RADS 2 and BI-RADS 3, while assessing the final US category. The review of the second-look US showed the size of the second malignant additional lesion ranged from 3 to 22 mm, of which 90% were smaller than 10 mm and 66% were smaller than 7 mm. Conclusions: Most additional malignant lesions, nonpalpable carcinomas, which were previously not detected by mammography and US at first-look diagnosis, were detected by a targeted second-look US examination. These lesions were of category BI-RADS 2 and BI-RADS 3 and smaller than 7 mm.

e11060 Background: One of the objections to wider use of breast MRI, e.g. in high risk screening, is its relatively high false positive rate. Particularly for subtle findings such as small enhancing foci, there is a shift from more aggressive approach to observation and close follow-up with MRI, (MR-Bi3). Our pilot study analyzed clinical outcomes of MR-Bi3 pts and the added value of such close follow up (f/u). Proportion of MR-Bi3 and MR-Bi3 after "second look ultrasound" (2ndUS) could be used among other monitors of BrMR practices, similar to a call-back rate in screening mammogram. Methods: We reviewed BIRAD categories assigned to all 743 BrMRs done in period of year 2007 in our specialized breast imaging practice utilizing dedicated BrMR system with full complement of other diagnostic and interventional modalities. Frequency of MR-Bi3 and inconclusive studies resulting in MR-Bi3 or biopsies after 2ndUS were analyzed. Triaging role of 2ndUS was evaluated. With benefit of 3 year clinical data, the outco...