Extremely dense breasts represent one of the major challenges in contemporary breast imaging. They are associated with a significant decrease in mammographic sensitivity and an increased risk of breast cancer, making screening more complex when it relies on a single modality.

In this context, the question is no longer whether mammography should be supplemented, but how to structure a coherent imaging pathway adapted to the patient’s profile and to clinical and organizational constraints. MRI, mammography, and ultrasound thus fit within a complementary logic aimed at achieving more effective screening.

Breast Density: A Major Impact on Detection

Breast density acts as a true masking effect, concealing lesions and reducing the visibility of abnormalities. In patients with extremely dense breasts, this masking effect is maximal, making mammography — even when combined with tomosynthesis — insufficient in a non-negligible number of cases.

Beyond this technical aspect, breast density is recognized as an independent risk factor. It must therefore be considered not only as an imaging constraint, but as a structuring element of the screening strategy.

Mammography and Tomosynthesis: An Essential but Limited Foundation

Mammography, combined with tomosynthesis, remains the entry point for screening. Tomosynthesis improves the separation of breast structures and enhances mass detection compared with 2D mammography.

However, in extremely dense breasts, these improvements may remain insufficient to fully overcome the masking effect, particularly for non-calcified invasive cancers. Complementary imaging is therefore necessary.

Breast MRI: The Reference Examination in Extremely Dense Breasts

Breast MRI is currently the most sensitive modality for detecting breast cancer, regardless of breast density. It combines detailed morphological analysis with functional information derived from dynamic and diffusion sequences, enabling precise lesion characterization.

Its absence of radiation exposure is a decisive advantage, particularly in personalized screening strategies and repeated follow-up. In the context of extremely dense breasts, MRI should no longer be considered a last-resort examination, but rather a structuring tool within the imaging pathway, especially in patients with intermediate or high risk.

Contrast-Enhanced Mammography (CEM): A Growing Complementary Functional Modality

CEM provides access to functional information based on tumor enhancement while maintaining a familiar mammographic framework. In extremely dense breasts, it helps overcome certain limitations of standard mammography by highlighting hypervascularized lesions.

CEM shows high performance in detecting invasive cancers, with good correlation with MRI for enhancing lesions. Its rapid execution and ease of integration into certain clinical workflows make it a particularly attractive option in specific organizational contexts or when MRI access is limited.

Breast Ultrasound: A Targeted Complement

Ultrasound retains an essential role in the localized exploration of abnormalities and in biopsy guidance. However, it does not represent a comprehensive response to the challenge posed by extreme breast density. Its use therefore fits within a targeted approach, complementing modalities that provide a more global and functional view.

Toward an Integrated Strategy

In patients with extremely dense breasts, the imaging strategy relies on a mammographic foundation complemented by an assessment of overall risk. MRI constitutes the reference examination when the objective is to optimize screening sensitivity, while CEM represents a relevant functional alternative or complement depending on the context. Ultrasound is used in a targeted manner, in response to specific clinical questions.

The management of extremely dense breasts fully illustrates the current evolution of breast imaging toward a personalized, multimodal, and clinically oriented approach.

MRI stands out as the reference in terms of sensitivity, while CEM and ultrasound provide complementary solutions adapted to varied clinical and organizational contexts.

Thoughtful coordination of these modalities helps improve early detection and develop more coherent imaging pathways better suited to patients.