Can Multimodal Decision Models Classify Breast Ultrasound Images? Benchmarking CLEF and CLEF-Flash Across Prompts and Datasets

Breast fibroadenoma (FA) and phyllodes tumor (PT) are fibroepithelial breast lesions with highly overlapping appearances on B-mode ultrasound, making benign and borderline PT prone to being misclassified as FA and complicating preoperative decision-making. Existing computer-aided diagnosis methods commonly rely on single-modal imaging features and insufficiently exploit complementary clinical and textual information. To address this limitation, we construct the FAPT-M Dataset, a pathology-confirmed multimodal dataset comprising 910 patients with strictly reviewed ultrasound images, structured clinical attributes, and ultrasound diagnostic descriptions. Based on this dataset, we propose a clinically guided multimodal framework that integrates DenseNet-based visual encoding, CLIP-inspired text encoding, and lightweight clinical encoding, and further introduces clinical-conditioned adaptive modulation, cross-modal Transformer fusion, and dual-path representation learning to improve feature alignment and multimodal interaction. Under patient-level five-fold cross-validation, the proposed method achieves an accuracy of 77.64%, F1-score of 73.38%, and AUC of 89.74%, outperforming representative CNN-, Transformer-, and vision-language-based baselines. Ablation studies and class-balanced evaluations further confirm the contribution of three-modality fusion and the key architectural components. Overall, this work provides an effective multimodal approach for fine-grained FA-PT classification and establishes a high-quality benchmark for multimodal breast ultrasound analysis.

Ultrasound interpretation requires both precise lesion localization and holistic clinical reasoning, yet existing methods typically excel at only one of these capabilities: specialized detectors offer strong localization but limited reasoning, whereas multimodal large language models (MLLMs) provide flexible reasoning but weak grounding in specialized medical domains. We present Echo-α, an agentic multimodal reasoning model for ultrasound interpretation that unifies these strengths within an invoke-and-reason framework. Echo-α is trained to coordinate organ-specific detector outputs, integrate them with global visual context, and convert the resulting evidence into grounded diagnostic decisions beyond detector-only inference. This behavior is established through a nine-task supervised curriculum and then refined by sequential reinforcement learning under different reward trade-offs, yielding Echo-α-Grounding for lesion anchoring and Echo-α-Diagnosis for final diagnosis. On multi-center renal and breast ultrasound benchmarks, Echo-α outperforms competitive baselines on both grounding and diagnosis. In particular, on cross-center test sets, Echo-α-Grounding attains 56.73%/43.78% [email protected] and Echo- α-Diagnosis reaches 74.90%/49.20% overall accuracy on renal/breast ultrasound. These results suggest that agentic multimodal reasoning can turn specialized detectors into verifiable clinical evidence, offering a practical route toward ultrasound AI systems that are more accurate, interpretable, and transferable. The repository is at https://github.com/MiliLab/Echo-Alpha.

Purpose: To evaluate the performance-feasibility tradeoffs of foundation models (FMs) and task-specific convolutional neural networks (CNNs) trained from scratch for breast implant classification in 2D mammography, with emphasis on suitability for near real-time clinical deployment. Methods: We evaluated four models: two FMs (RAD-DINO and MammoCLIP) and two CNNs trained from scratch for implant prediction (ResNet18 and our lightweight ResNetLite). Using the Emory Breast Imaging Dataset, 5,000 unilateral screening mammograms were used for training/validation and 1,000 manually reviewed unilateral images were held out for testing. For the FMs, global image embeddings from the pretrained encoder were classified using a support vector machine (SVM). The CNNs were trained end-to-end on 2D mammograms, with ResNetLite optimized via grid search over depth and width to balance accuracy and efficiency. Performance was evaluated using AUROC, sensitivity, specificity, accuracy, embedding visualization, and inference-latency. Results: All models demonstrated strong performance on held-out test data (n = 1,000). MammoCLIP achieved the highest AUROC (0.999) with the quickest training time of 493 seconds. RAD-DINO achieved the highest sensitivity (0.980; accuracy 0.989) but had the slowest inference and training times. ResNet18 and MammoCLIP achieved comparable accuracy (0.985). ResNetLite showed no statistically significant difference from ResNet18 (AUROC 0.993; accuracy 0.976) despite using only 1.4% of ResNet18's parameters, and had the fastest inference time. Conclusion: FMs and task-specific CNN models reliably detect breast implants on 2D mammography. Model selection is best guided by deployment context: MammoCLIP for GPU-equipped hospital settings requiring scalable integration, and lightweight CNNs such as ResNetLite for resource-constrained or edge deployments.