Contrast-Enhanced Mammography as a Functional Biomarker in Breast Cancer: Correlation of Enhancement Patterns with Ki-67 and Histological Grade

Background: Contrast-Enhanced Spectral Mammography (CESM) combines anatomical and functional imaging, showing promise in breast cancer diagnosis. Despite well-established lesion detection accuracy, few studies have investigated the link between CESM enhancement patterns and tumor aggressiveness biomarkers. Methods: We retrospectively evaluated 100 patients (mean age 59.5 years) undergoing CESM with complete histopathological data. Lesions were categorized by enhancement intensity (high, medium, low) and contrast homogeneity (homogeneous vs. heterogeneous), correlated with Ki-67 index and histological grade. Results: Lesion size measured by CESM closely matched histology (mean 2.16 cm vs. 2.25 cm). Mass-like lesions corresponded mainly to invasive ductal carcinoma, while non-mass patterns aligned with lobular or in situ carcinomas. Enhancement intensity correlated moderately with Ki-67 (Spearman ρ = 0.56, p < 0.001), and contrast heterogeneity showed a weaker but significant correlation with tumor grade (ρ = 0.22, p < 0.05). Conclusions: CESM accurately assesses tumor size and provides functional insight into tumor biology. Enhancement intensity may serve as a non-invasive proliferation marker, while contrast heterogeneity offers additional prognostic data, supporting CESM’s role in personalized breast cancer management.