Breast cancer staging with contrast-enhanced imaging. The benefits and drawbacks of MRI, CEM, and dedicated breast CT

Pretherapeutic breast cancer staging is pivotal for patient-centered disease management, guiding treatment stratification and assessing prognostic outcomes. Breast imaging plays a key role in both anatomic and prognostic staging by providing comprehensive insights into disease extent, localization, and tumor aggressiveness characteristics. To date, clinical image-based staging relies on conventional modalities such as digital mammography (DM), digital breast tomosynthesis (DBT), and ultrasound. Considering the phenotypic disparities of breast cancer and their relation to treatment response, other imaging techniques based on contrast-enhanced mechanisms, which highlight areas of increased neovascularity, appear indispensable in breast cancer staging. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) offers a comprehensive 3-dimensional assessment of extent of disease and characterization of lesions, capturing both morphological and functional aspects which are crucial for treatment and monitoring of the disease. Based on this established approach, contrast-enhanced x-ray-based techniques, with high spatial resolution, such as contrast-enhanced mammography (CEM) and dedicated contrast-enhanced breast computed tomography (dCEBCT), have emerged. This review outlines the current status, limitations, and ongoing challenges associated with each one contrast-enhanced imaging modality, while emphasis is given to key breast cancer manifestations and the optimal interpretation of their imaging phenotypes, in the current era of image-based (anatomic and prognostic) breast cancer staging.