Real-time virtual sonography for prone-position breast MRI: technical feasibility and accuracy in locating 125 breast lesions

OBJECTIVE: This study evaluates the feasibility and technical success rate of real-time virtual sonography (RVS) for prone contrast-enhanced breast MRI sequences during second-look examinations. Usually, additional supine MRI sequences are acquired for coregistration. MATERIALS AND METHODS: This single-center retrospective study was performed in a cohort of female patients who underwent contrast-enhanced prone breast MRI followed by second-look ultrasound for MRI-detected incidental lesions. RVS was used to coregister supine ultrasound and prone MRI data without requiring additional supine MRI studies. Lesion localization success, as well as lesion visibility, fusion quality, and histopathological correlation through ultrasound-guided biopsy, were assessed. A covariate analysis of factors affecting lesion localization was performed. RESULTS: A total of 103 female patients (mean age 48.3 ± 11.0 years) with 125 MRI-detected breast lesions were included. Of the lesions, 91.2% were successfully localized using RVS, including a high proportion of non-mass enhancements (41.6%). Ultrasound-guided biopsy was performed in 57.6% of cases, confirming malignancy in 31.9% of those. Covariate analysis identified higher breast volume as the only factor significantly associated with reduced RVS coregistration success (odds ratio 0.993, p = 0.035). CONCLUSION: RVS represents an advanced imaging approach in breast diagnostics, offering a promising solution to overcome the limitations of standalone modalities and potentially enhance diagnostic accuracy. We showed that prone MRI studies may be sufficient for RVS-based coregistration of breast lesions, potentially rendering additional supine MRI acquisitions unnecessary. RELEVANCE STATEMENT: This study demonstrates that real-time virtual sonography with contrast-enhanced MRI in the prone position is a feasible and effective method for localizing MRI-detected breast lesions on second-look ultrasound without the need for additional supine MRI. This approach can optimize diagnostic workflows and reduce imaging burden while maintaining high localization rates. KEY POINTS: RVS localizes MRI-detected breast lesions in the prone position without requiring additional supine MRI for co-registration. Successful localization was achieved in 91.2%, including 41.6% non-mass enhancements, with higher breast volume as the only detrimental factor. RVS enables accurate lesion localization without supine MRI, streamlining workflows, lowering imaging costs, and improving biopsy access.