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Independent value of image fusion in unenhanced breast MRI using diffusion-weighted and morphological T2-weighted images for lesion characterization in patients with recently detected BI-RADS 4/5 x-ray mammography findings

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The aim of this study was to evaluate the accuracy and applicability of solitarily reading fused image series of T2-weighted and high-b-value diffusion-weighted sequences for lesion characterization as compared to sequential or combined image analysis of these unenhanced sequences and to contrast- enhanced breast MRI.


This IRB-approved study included 50 female participants with suspicious breast lesions detected in screening X-ray mammograms, all of which provided written informed consent. Prior to biopsy, all women underwent MRI including diffusion-weighted imaging (DWIBS, b = 1500s/mm2). Images were analyzed as follows: prospective image fusion of DWIBS and T2-weighted images (FU), side-by-side analysis of DWIBS and T2-weighted series (CO), combination of the first two methods (CO+FU), and full contrast-enhanced diagnostic protocol (FDP). Diagnostic indices, confidence, and image quality of the protocols were compared by two blinded readers.


Reading the CO+FU (accuracy 0.92; NPV 96.1 %; PPV 87.6 %) and the CO series (0.90; 96.1 %; 83.7 %) provided a diagnostic performance similar to the FDP (0.95; 96.1 %; 91.3 %; p > 0.05). FU reading alone significantly reduced the diagnostic accuracy (0.82; 93.3 %; 73.4 %; p = 0.023).


MR evaluation of suspicious BI-RADS 4 and 5 lesions detected on mammography by using a non-contrast-enhanced T2-weighted and DWIBS sequence protocol is most accurate if MR images were read using the CO+FU protocol.

Key Points

Unenhanced breast MRI with additional DWIBS/T2w-image fusion allows reliable lesion characterization.

Abbreviated reading of fused DWIBS/T2w-images alone decreases diagnostic confidence and accuracy.

Reading fused DWIBS/T2w-images as the sole diagnostic method should be avoided.

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Side-by-side analysis of DWIBS and T2-weighted series


Combined reading the CO and the FU series


Diffusion-weighted imaging


Diffusion-weighted imaging with background suppression


Full contrast-enhanced diagnostic protocol


Fused image series of diffusion-weighted and T2-weighted images


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The scientific guarantor of this publication is Prof. Dr. med. Dipl.-Phys. Heinz-Peter Schlemmer. The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. This study has received funding by the Dietmar-Hopp-Foundation (non-profit, Germany). One of the authors has significant statistical expertise. Institutional Review Board approval was obtained. Written informed consent was obtained from all subjects (patients) in this study.

Some study subjects or cohorts have been previously reported in another context in “Bickelhaupt S, Laun F, Tesdorff J, et al. Fast and non-invasive characterization of suspicious lesions detected on X-ray breast cancer screening– capability of diffusion weighted MRI with maximum intensity projections. Radiology. 2015.” A copy of this manuscript is attached to the submission.

Methodology: Retrospective within a prospective study, diagnostic study, multicenter study.

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Correspondence to Sebastian Bickelhaupt.

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Bickelhaupt, S., Tesdorff, J., Laun, F.B. et al. Independent value of image fusion in unenhanced breast MRI using diffusion-weighted and morphological T2-weighted images for lesion characterization in patients with recently detected BI-RADS 4/5 x-ray mammography findings. Eur Radiol 27, 562–569 (2017).

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