Contrast-Enhanced Spectral Mammography (CESM) in the Further Evaluation of BI-RADS 3–4A Breast Lesions: а Systematic Literature Review

Objective . To perform a systematic literature review to evaluate the diagnostic performance of contrast-enhanced spectral mammography (CESM) in women with BI-RADS 3–4A breast lesions and to assess its impact on lesion reclassification, biopsy rates, and management strategy. Materials and Methods . A literature search was conducted in PubMed, Web of Science, Scopus, MedVis, and the Russian Science Citation Index for the period 2015 – January 2025, including original clinical studies, systematic reviews, and meta-analyses comparing CESM with digital mammography, ultrasound, and MRI in patients classified as BI-RADS 3–4A. Results . CESM demonstrated high sensitivity (92.7–100 %) and specificity (67.9–100 %), outperforming digital mammography, and allowed safe downgrading of 20–40 % of probably benign lesions to BI-RADS 2, reducing the number of biopsies by 16–43 % while maintaining a high negative predictive value. Conclusion . CESM is an effective method for further evaluation of BI-RADS 3–4A lesions and dense breast tissue, reduces unnecessary biopsies and short-interval follow-up, and can be considered a cost-effective alternative to MRI in resource-limited settings.