Contrast-enhanced mammography-guided biopsy: principles, challenges, and opportunities.

Contrast-enhanced mammography (CEM)-guided biopsy enables the tissue sampling of enhancing breast lesions that are not visible on conventional imaging. The technique combines dual-energy stereotactic acquisition with intravenous contrast administration, allowing accurate targeting of recombined-only lesions. It represents a practical alternative to MRI-guided biopsy, particularly in settings where MRI access is limited or contraindicated. This review examines current evidence, procedural experience, and challenges associated with CEM guidance. Early studies support its technical feasibility, although data remain scarce and heterogeneous regarding lesion selection, procedural experience, and outcome definitions. Broader implementation is challenged by equipment specifications, contrast administration practices, logistics, and reimbursement issues. As clinical adoption increases, structured patient triage pathways, standardised protocols, and prospective validation are essential. CEM-guided biopsy is a promising technique in breast imaging and has the potential to reduce reliance on MRI guidance. However, further research is required to define its role and ensure consistent performance across clinical settings. CRITICAL RELEVANCE STATEMENT: This review critically examines current evidence, technical feasibility, and implementation challenges of contrast-enhanced mammography-guided biopsy. It highlights potential advantages for clinical settings where MRI guidance is limited, while addressing existing limitations and areas that require further research. KEY POINTS: Contrast-enhanced mammography-guided biopsy is a dual-energy stereotactic procedure that enables the targeting of enhancing lesions that lack conventional imaging correlates. The modality is accurate and feasible, though its implementation is challenged by technical heterogeneity and the absence of standardised protocols. Broader clinical adoption requires structured diagnostic workflows, validated contrast administration strategies, and prospective multicentre evaluation.