Preoperative Breast MRI in Surgical Decision-Making for Breast Cancer: Clinical Value Beyond Sensitivity

Background: Preoperative contrast-enhanced breast imaging, particularly magnetic resonance imaging (MRI) and contrast-enhanced mammography (CEM), has become increasingly integrated into the surgical management of breast cancer. Although these techniques improve detection of multifocal, multicentric, and contralateral disease, their clinical value cannot be defined by sensitivity alone. Methods: This article was conceived as a critical narrative review supported by a targeted literature search primarily conducted in PubMed/MEDLINE, with additional cross-checking in Scopus and reference lists. English-language studies addressing preoperative MRI or CEM in relation to surgical planning, re-excision, mastectomy, additional disease detection, and oncologic outcomes were prioritized. Overall, 38 clinically relevant studies were included in the qualitative narrative synthesis. Results: A decision-oriented reading of the literature suggests that preoperative contrast-enhanced imaging does not produce a uniform clinical effect, but rather reshapes management through recurring patterns. Three main patterns can be identified: (1) refinement of surgical extent through improved disease mapping, most clearly in invasive lobular carcinoma, where MRI may reduce repeat surgery without consistently increasing mastectomy rates; (2) pre-emptive escalation aimed at avoiding reoperation, particularly in ductal carcinoma in situ, where lower re-excision rates are often accompanied by higher initial mastectomy rates; and (3) decision amplification driven by the detection of additional or indeterminate disease, frequently resulting in additional biopsies and treatment escalation without consistent evidence of long-term oncologic benefit. Across large observational cohorts, routine preoperative MRI has not been consistently associated with improvements in overall survival, disease-free survival, or locoregional control in unselected populations. These patterns should be understood as interpretive categories derived from recurring trends in a heterogeneous literature, rather than as formally validated decision classifications. Conclusions: The value of preoperative contrast-enhanced breast imaging depends less on sensitivity itself than on how imaging findings are translated into surgical action. Selective, question-driven use appears most valuable in settings such as invasive lobular carcinoma and assessment of nipple-areola complex involvement, whereas routine use in unselected populations often appears to increase surgical intensity more clearly than it improves long-term oncologic outcomes. Contrast-enhanced imaging should therefore be regarded as a decision-shaping tool whose clinical usefulness depends on explicit interpretive and multidisciplinary thresholds.