Contrast-enhanced mammography in the setting of neoadjuvant therapy from a multidisciplinary perspective

Contrast-enhanced mammography (CEM) is a morphofunctional imaging technique that is gaining interest and acceptance in clinical practice. With increasing use of neoadjuvant therapy (NAT) in breast cancer and of precision medicine, the need for equitable access to appropriate high-quality advanced imaging for monitoring response has become ever more relevant. CEM is an imaging alternative for NAT monitoring, with encouraging initial results and a good logistical profile. In this educational review from a practical perspective, we explore key aspects for response assessment of NAT and CEM roles in this setting, based on relevant literature and the authors' clinical experience. Pearls and pitfalls, as well as opportunities and challenges for NAT monitoring with CEM, will be approached from the perspectives of the radiologist, the oncologist, the surgeon, the pathologist, and the patient. CRITICAL RELEVANCE STATEMENT: The early experience with CEM in the NAT setting is positive, encouraging its further development, not only from the radiologist's view but also from a broad multidisciplinary perspective. KEY POINTS: CEM seems to be non-inferior to MRI for response evaluation and preoperative re-staging after NAT. CEM may predict and monitor in vivo chemosensitivity during NAT. CEM may allow a greater patient flow rate compared to MRI.