According to the World Health Organization, breast cancer was the most commonly diagnosed cancer among women in 2022, with 2.3 million new cases and 666,000 deaths worldwide [1]. Standard treatment typically involves surgery, with or without radiotherapy and/or systemic therapy, depending on the stage and subtype of the disease. In recent years, trials have focused on less invasive surgical approaches and individualized systemic therapies aimed at treatment de-escalation, with imaging playing a central role in accurate lesion assessment [[2], [3], [4], [5], [6]].

Dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) plays a central role in the diagnosis of breast cancer, including determining the need for biopsy, tumor staging, and evaluating the systemic treatment response. Standard acquisition and interpretation of breast MRI follow the Breast Imaging Reporting and Data System (BI-RADS), which requires DCE MRI with both early and delayed phase imaging after intravenous administration of a gadolinium-based contrast agent (GBCA) [7]. A notable Japanese multicenter study reported that combining morphological evaluation based on BI-RADS with patient age, tumor location, and background parenchymal enhancement achieved high diagnostic accuracy in distinguishing malignant from benign breast lesions, with an area under the receiver operating characteristic curve of 0.925 for masses and 0.829 for non-mass enhancements [8]. Furthermore, faster acquisition protocols are gaining attention. Abbreviated MRI has been shown to detect breast cancer as effectively as full-protocol DCE MRI, while ultrafast DCE MRI provides more detailed evaluation of breast cancer [9,10]. The integration of deep learning is also being explored as a means of improving diagnostic accuracy and reducing variability in lesion assessment [11].

Although the value of DCE MRI in current breast cancer diagnosis is undeniable, the long-term sustainability of contrast-enhanced MRI is under re-evaluation. Side effects can occur following the injection of GBCA, with fatal anaphylaxis reported at a frequency of 0.01 % [12]. The administration of GBCA is contraindicated in certain patients, such as pregnant women and those with severe renal failure. In addition, concerns have arisen regarding GBCA accumulation in the brain and bones, as well as its broader environmental impact [13,14]. Anthropogenic GBCA contamination poses risks to aquatic ecosystems, where gadolinium can bioaccumulate in marine organisms and disrupt essential biological processes. Growing awareness of the environmental footprint of medical imaging, together with issues of cost and accessibility, has fueled a call for more sustainable practices in radiology.

The purpose of this review was to highlight emerging GBCA -free imaging modalities, including non-contrast MRI, computed tomography (CT), and positron emission tomography (PET), that may serve as alternatives to DCE MRI for more sustainable breast cancer diagnosis and to provide a comprehensive overview of recent innovations and novel tracer developments.