Quantifying radiation exposure in contrast-enhanced stereotactic breast biopsy: considerations for dose optimization

Abstract Objectives This secondary analysis of a prospective single-center observational study aimed to quantify the average glandular dose (AGD) of contrast-enhanced stereotactic biopsy (CESB), including the prerequisite contrast-enhanced mammography (CEM), and to identify procedural steps that may offer future opportunities for protocol optimization. Materials and methods This analysis included patients aged 18 years or older with recombined-only lesions on CEM referred for CESB. Eligible lesions were visible only on recombined CEM images, not on low-energy (LE) CEM images, tomosynthesis, or (targeted) ultrasound obtained as part of their routine work-up. Dose information for both CEM and CESB was extracted from the mammography units. For CESB, AGD was determined for each procedural step. Results Between October 2023 and July 2025, 62 patients underwent CESB (mean age 58 ± 10 years; mean compressed breast thickness 52 ± 11 mm). The standardized vendor-protocol estimated CESB AGD was 22.8 ± 7.2 mGy. Scout images averaged 2.7 ± 0.9 mGy, and paired acquisitions 5.0 ± 1.6 mGy each. Preceding CEM contributed 6.1 ± 2.1 mGy, yielding a cumulative 28.9 ± 7.5 mGy per biopsied breast. AGD increased with compressed breast thickness. Evaluation of the CESB protocol indicated that potential targets for dose reduction, namely the post-fire acquisitions (low-energy and high-energy) and high-energy marker-deployment acquisitions, accounted for 6.0 ± 1.9 mGy, 26% of the total radiation dose. Conclusion CESB results in an estimated mean AGD of 22.8 mGy, with a cumulative dose of 28.9 mGy per biopsied breast including the preceding CEM. In this observational cohort, omission of post-fire acquisitions and limiting post-marker imaging to a low-energy acquisition may serve as future targets for dose-reduction strategies. Trial registration ClinicalTrials.gov, NCT06062992. Registered 10 October 2023, https://clinicaltrials.gov/study/NCT06062992 . Key Points Question What is the stepwise radiation dose of contrast-enhanced stereotactic biopsy, including preceding contrast-enhanced mammography, and can protocol refinements reduce unnecessary exposure? Findings Contrast-enhanced stereotactic biopsy delivered 22.8 mGy on average, preceding mammography added 6.1 mGy, and omitting selected acquisitions could reduce biopsy dose by 26%. Relevance statement Quantifying the dose contribution of each imaging step may help clinicians balance procedural workflow and radiation exposure in contrast-enhanced stereotactic breast biopsy.