Contrast-enhanced mammography (CEM) is a relatively new imaging technique that allows morphologic, anatomic and functional imaging of the breast. The aim of our study was to validate contrast-enhanced mammography (CEM) compared to mammography (MMG) and digital breast tomosynthesis (DBT) in daily clinical practice. This retrospective study included 316 consecutive patients who underwent MMG, DBT and CEM at the Centre for Prevention and Diagnosis of Chronic Diseases of Primorsko-goranska County. Two breast radiologists independently analyzed the image data, without available anamnestic information and without the possibility of comparison with previous images, to determine the presence of suspicious lesions and their morphological features according to the established criteria of the Breast Imaging Reporting and Data System (BI-RADS) lexicon. The diagnostic value of MMG, DBT and CEM was assessed by ROC analysis. The interobserver agreement was excellent. CEM showed higher diagnostic accuracy in terms of sensitivity and specificity compared to MMG and DBT, the reporting time for CEM was significantly shorter, and CEM findings resulted in a significantly lower proportion of equivocal findings (BI-RADS 0), suggesting fewer additional procedures. In conclusion, CEM achieves high diagnostic accuracy while maintaining simplicity, reproducibility and applicability in complex clinical settings.

Background: Accurate delineation of ductal carcinoma in situ (DCIS) remains a key challenge in surgical planning. Although contrast-enhanced mammography (CEM) improves lesion detection, its clinical role in informing individualized surgical strategies remains unclear. This study evaluated the impact of CEM on preoperative assessment and surgical planning, with particular emphasis on whether its effect varies across patient subgroups. Methods: This multicentre pilot observational cohort study included 102 patients: 51 prospective patients undergoing preoperative CEM and mammography (MMG) and 51 retrospective controls assessed with MMG alone. Imaging-derived lesion size and planned resection volume were compared with pathological size using correlation analysis, intraclass correlation coefficient (ICC), and Bland–Altman methods. Surgical outcomes were assessed, and subgroup analyses explored differences according to CEM enhancement status. Results: CEM showed improved correlation with pathological DCIS size compared with MMG (ρ = 0.54 vs. 0.37), with the strongest agreement in CEM-positive lesions (ρ = 0.67; ICC 0.745). However, its clinical impact was not uniform. At the population level, CEM did not significantly change planned resection volume or surgical thresholds. In contrast, in CEM-positive patients, CEM was associated with larger planned resections, proportional to pathological tumor burden. Reoperation rates were lower in the CEM cohort (5.9% vs. 17.6%), without statistical significance, and margin status was comparable. Conclusions: The impact of CEM on surgical planning in DCIS is heterogeneous and largely confined to patients with enhancing lesions. These findings suggest that the value of CEM may lie in its selective use, where it can refine assessment of disease extent in specific subgroups rather than in routine application. Further studies incorporating predictive approaches are needed to support risk-adapted imaging strategies.