How to optimise breast cancer staging with contrast-enhanced mammography: current evidence and clinical implications

Contrast-enhanced mammography (CEM) is a functional breast imaging technique that combines conventional mammographic morphology with contrast-based assessment of tumour vascularity. In the presurgical setting, CEM has gained interest as a tool to improve local staging by refining tumour extent evaluation and detecting additional disease beyond conventional imaging. This narrative review critically summarises current evidence on the role of CEM in preoperative breast cancer staging. Technical aspects, diagnostic performance for index lesion size assessment and detection of additional malignant foci, comparison with breast MRI, and impact on surgical planning are discussed, with attention to histological subtypes and clinically relevant scenarios encountered in daily practice. Available studies suggest that CEM provides tumour extent assessment comparable to MRI in selected settings, with higher specificity for additional lesions and meaningful influence on surgical decision-making. However, limitations related to contrast administration, radiation dose, evaluation of posterior structures, and nodal staging remain. Heterogeneity in protocols and outcome definitions also limits generalizability. CEM represents a valuable adjunct for presurgical breast cancer staging when appropriately integrated into multimodality workflows. Prospective multicenter studies are needed to define its impact on surgical outcomes and clarify its role within personalised breast cancer management. CRITICAL RELEVANCE STATEMENT: This review provides a critical overview of CEM in preoperative breast cancer staging, highlighting its role as a complementary imaging tool when MRI is unavailable or unsuitable, and emphasising the need for prospective multicentre studies to validate its clinical impact. KEY POINTS: To define the role of CEM in preoperative breast cancer staging, focusing on tumour extent, detection of additional disease, and implications for surgical planning. CEM improves tumour extent assessment and detection of additional lesions, showing performance similar to MRI in selected clinical scenarios and influencing surgical planning in approximately 20-30% of patients.