Breast cancer imaging without gadolinium-based contrast agent: A review of current applications and future trends

Dynamic contrast-enhanced magnetic resonance imaging remains a cornerstone of breast cancer diagnosis, yet concerns regarding the safety, environmental impact, and cost of gadolinium-based contrast agents are driving the development of gadolinium-based contrast agent-free alternatives. This review outlines emerging non-contrast imaging modalities that support a more sustainable approach to breast cancer diagnosis. Advanced MRI techniques, such as diffusion-weighted imaging and synthetic MRI, provide detailed tissue characterization without the need for contrast agents. In computed tomography (CT), innovations including dual-energy CT and photon-counting detector CT are improving lesion detection and characterization, with photon-counting detector CT offering exceptional spatial resolution. Molecular imaging with positron emission tomography is also advancing beyond ¹⁸F-fluorodeoxyglucose, incorporating dedicated high-resolution systems and novel tracers targeting specific biomarkers, such as 16α-¹⁸F-fluoro-17β-estradiol for estrogen receptors, fibroblast activation protein inhibitors, and human epidermal growth factor receptor 2-targeted agents. The future of breast imaging is likely to adopt a multimodal strategy, combining these innovations to deliver more accurate, personalized, and sustainable patient care.