Clinical Scorecard: Comparison of Contrast-Enhanced Mammography and Breast MRI for Preoperative Assessment of the Nipple-Areola Complex: Insights from Real-World Data

At a Glance

Key Highlights

• MRI is the current gold standard for preoperative locoregional staging with high sensitivity (71%) and specificity (94%) for NAC involvement.
• Contrast-enhanced mammography (CEM) is emerging as a reliable, faster, and more accessible alternative, especially for patients aged ≥60 or those contraindicated for MRI.
• Histopathological evaluation of surgical specimens remains the reference standard for confirming NAC involvement.

Guideline-Based Recommendations

Diagnosis

• Use MRI for preoperative locoregional staging of breast cancer, especially in younger patients or those without contraindications.
• Consider CEM as an alternative imaging modality for patients aged ≥60 years or with MRI contraindications.
• Confirm NAC involvement histologically via surgical specimen analysis including invasive carcinoma, DCIS, or Paget’s disease cells.

Management

• Avoid nipple-sparing procedures if NAC involvement is detected.
• Select imaging modality based on patient age, MRI suitability, and institutional protocols.
• Use imaging findings to optimize surgical planning balancing oncological safety and aesthetic outcomes.

Monitoring & Follow-up

• Perform standardized image interpretation by experienced radiologists blinded to clinical and histopathological data except tumor location.
• Use consistent imaging protocols for CEM and MRI to ensure diagnostic accuracy.
• Correlate imaging findings with histopathological results for continuous quality assessment.

Risks

• MRI involves no ionizing radiation but may be contraindicated in some patients.
• CEM involves ionizing radiation and iodinated contrast, requiring consideration of radiation protection principles, especially in younger patients.
• Inaccurate assessment of NAC involvement may lead to inappropriate surgical choices compromising oncological safety.

Patient & Prescribing Data

Women with biopsy-proven breast cancer undergoing preoperative imaging; CEM preferentially used in women aged ≥60 or with MRI contraindications.

CEM offers a potentially faster, more accessible, and better tolerated alternative to MRI for NAC assessment, facilitating surgical decision-making in selected patient groups.

Clinical Best Practices

• Adhere to institutional policies allocating imaging modality based on patient age and MRI suitability.
• Ensure radiologists meet EUSOMA and European Cancer Concord expert criteria for breast imaging interpretation.
• Standardize imaging evaluation criteria through training sessions prior to study readings.
• Use histopathological examination as the definitive standard for NAC involvement confirmation.
• Incorporate both low-energy and recombined images in CEM interpretation for comprehensive assessment.

References

• European Society of Breast Cancer Specialists (EUSOMA) criteria
• College of American Pathologists guidelines