Magnetic resonance imaging in breast cancer management: current applications, limitations, and future directions

Magnetic resonance imaging (MRI) has emerged as a cornerstone of breast cancer management, demonstrating superior sensitivity compared to mammography and ultrasound, particularly for high-risk screening and the evaluation of dense breast tissue. Beyond detection, MRI provides critical physiologic and anatomical assessment essential for accurate staging, visualizing invasive lobular carcinoma, and identifying multifocal or multicentric disease. It also plays a vital role in monitoring therapeutic response to neoadjuvant chemotherapy by distinguishing between concentric tumor shrinkage and fragmentation, a distinction that directly influences surgical eligibility. Despite these diagnostic advantages, the indications for preoperative MRI remain controversial. This review examines the tension between MRI's utility in surgical planning-specifically its association with reduced positive margins and lower re-excision rates-and concerns regarding overdiagnosis, increased mastectomy rates, and false-positive findings. Logistical barriers to widespread adoption, including cost-effectiveness, gadolinium concerns, and the need for standardized interpretation protocols, are also discussed. Finally, the article highlights transformative advancements designed to address these limitations. Technologies such as abbreviated (AB-MRI) and ultrafast acquisition protocols promise to maximize patient throughput and capture essential kinetic data, while diffusion-weighted imaging (DWI) and artificial intelligence (AI) aim to enhance diagnostic specificity and workflow efficiency. The review also considers contrast-enhanced mammography (CEM) as a growing alternative for patients unable to undergo MRI. As evidence evolves, the integration of these technologies points toward a future of precision medicine, where breast imaging is rigorously tailored to individual patient risk and biological profiles.