Contrast-enhanced mammography versus breast MRI in the preoperative evaluation of the nipple-areola complex: data from a real-world setting

Objectives: Accurate preoperative assessment of nipple-areolar complex (NAC) involvement is critical for surgical planning in breast cancer patients. While magnetic resonance imaging (MRI) is the established modality for NAC evaluation, contrast-enhanced mammography (CEM) has emerged as a potential alternative. This study aims to compare the diagnostic performance of CEM and MRI in predicting NAC involvement in a real-world setting, using histopathology as the reference standard. Materials and methods: A retrospective cohort of 195 women with biopsy-proven breast cancer (91 CEM, median age 66 years; 104 MRI, 53 years) underwent preoperative imaging at a single institution. Imaging criteria for NAC involvement were defined. Two radiologists independently evaluated the images, with discordances resolved by consensus. Diagnostic performance was compared between CEM and MRI using Fisher’s exact test. Multivariable logistic regression identified predictors of NAC involvement. Results: NAC involvement was histologically confirmed in 11.0% (10/91) CEM and 19.2% (20/104) MRI cases (p = 0.110). Sensitivity was similar, 60% for CEM and 50% for MRI (p = 0.897), with nearly identical specificity (96.3% vs. 96.4%; p = 0.709). In situ components were frequently observed in NAC-positive cases (CEM: 90%; MRI: 75%) but were not statistically predictive. Independent predictors included peri-areolar thickening for CEM (OR 26.3; 95% CI 3.9–100; p = 0.0007) and abnormal NAC enhancement (OR 14; 95% CI 1.5–133.5; p < 0.001) and shorter tumor-to-nipple distance (OR 0.28, 95% CI 0.1–0.6; p < 0.001) for MRI. Conclusions: Notwithstanding a difference in patient age between the CEM and MRI cohorts, which mirrors the different clinical application of the two imaging modalities, CEM demonstrated diagnostic performance comparable to MRI for NAC assessment, offering high specificity and clinical utility in patients unsuitable for MRI. Key imaging features (e.g., peri-areolar thickening, NAC enhancement) aid preoperative decision-making. These findings support CEM as a viable alternative for NAC evaluation, particularly in cases of contraindications to MRI. Key Points: Question Preoperative assessment of nipple-areola complex (NAC) involvement in breast cancer impacts surgical decisions. It is unclear whether contrast-enhanced mammography (CEM) may provide diagnostic performance comparable to magnetic resonance imaging (MRI) in assessing NAC involvement. Findings CEM and MRI show comparable diagnostic performance for NAC involvement, with similar sensitivity, specificity, and predictive values. Clinical relevance CEM offers a reliable, accessible alternative to MRI for evaluating NAC involvement, supporting surgical planning in breast cancer patients, especially when MRI is contraindicated or unavailable.