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Eligible English-language articles published until August 2024 focused on CE-MRI in high-risk lesions. Two reviewers extracted data on true positives (TP), false positives (FP), true negatives (TN), and false negatives (FN). Sensitivity, specificity, negative and positive likelihood ratios were calculated using a bivariate random-effects model. Fagan nomograms identified the maximum pretest probability at which post-test probabilities of a negative MRI matched the 2% malignancy threshold used for downgrading BI-RADS 4 to 3. I\u00b2 statistics and meta-regression explored heterogeneity.\n                      <jats:italic>p<\/jats:italic>\n                      -values\u2009&lt;\u20090.05 were considered significant.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Seven studies comprising 479 patients with 493 high-risk lesions undergoing CE-MRI were included. The average breast cancer prevalence was 17% (88\/493). Pooled sensitivity was 91.3% (95% CI: 82.8\u201395.8%) and pooled specificity was 68.8% (95% CI: 50.3\u201382.8%). Only 6\/493 malignancies were missed by CE-MRI; all were small low-grade ductal carcinoma in situ (DCIS). Fagan nomograms indicated that CE-MRI could rule out malignancy in lesions with pretest probabilities up to 13.1%.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>CE-MRI in assessing high-risk lesions may help identify patients who can safely avoid surgery, potentially reducing morbidity, anxiety, and healthcare resource use. Malignancy can be reliably ruled out in lesions with pretest probabilities \u2264 13.1%, although prospective studies are suggested for confirmation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Key Points<\/jats:title>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Question<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>Can contrast-enhanced breast MRI help to rule out malignancy in patients with high-risk lesions at imaging-guided biopsy, thereby supporting more tailored decisions and potentially reducing unnecessary surgical excisions?<\/jats:italic>\n                    <\/jats:p>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Findings<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>Contrast-enhanced breast MRI may reduce unnecessary surgical or vacuum excisions in high-risk (B3) lesions. Missed cancers were limited to small low-grade DCIS.<\/jats:italic>\n                    <\/jats:p>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Clinical relevance<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>Contrast-enhanced breast MRI may support the identification of patients with high-risk lesions who could potentially avoid surgery. This non-invasive approach has the potential to reduce overtreatment, healthcare costs, and patient anxiety, while maintaining a high negative predictive value.<\/jats:italic>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00330-025-12291-9","type":"journal-article","created":{"date-parts":[[2026,1,16]],"date-time":"2026-01-16T23:48:14Z","timestamp":1768607294000},"page":"4434-4444","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Potential role of breast MRI to identify patients with high-risk lesions who might avoid surgery: a systematic review and meta-analysis"],"prefix":"10.1007","volume":"36","author":[{"given":"Giulia","family":"Vatteroni","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nina","family":"Pirringer-P\u00f6tsch","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paola","family":"Clauser","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3755-5398","authenticated-orcid":false,"given":"Pascal A. 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