The CESM dose for system 1 is within an acceptable range as compared with other commonly performed mammographic examinations and should not preclude its use as a diagnostic breast imaging tool.

Purpose Water equivalent diameter (WED) is a robust patient‐size descriptor. Localizer‐based WED estimation is less sensitive to truncation errors resulting from limited field of view, and produces WED estimates at different locations within one localizer radiograph, prior to the initiation of axial scans. This method is considered difficult to implement by the clinical community due to the necessary calibration between localizer pixel values (LPV) and attenuation, and the unknown stability of calibration results across scanners and over time. We investigated the stability of calibration results across 25 computed tomography (CT) scanners from three medical centers, and their stability over 3 ∼ 29 months for 14 of those scanners. Methods Localizer and axial images of ACR and body computed tomography dose index phantoms were acquired, using routine clinical techniques (120 kV and lateral localizers) on each of the 25 CT scanners: 8 GE scanners (CT750HD, VCT, and Revolution), 8 Siemens scanners (Definition AS, Force, Flash, and Edge), 5 Canon scanners (Aquilion‐One, Aquilion‐Prime80, and Aquilion‐64), and 4 Philips scanners (iCT 256, iQon, and Ingenuity). By associating axial images with the corresponding localizer lines, the relationship between the scaled water equivalent area (WEA) and averaged LPV were established through regression analysis. Results Linear relationships between the scaled WEA and the averaged LPV were observed in all 25 CT scanners (R2>0.999). Calibration parameters were similar for CT scanners from the same vendor: the coefficients of variation (COV) were ≤ 1% in all four vendor groups for the calibration slope, and < 7% for the intercept. By analyzing the deviation of WED resulted from errors in the calibration slope or intercept alone, we derived the tolerance ranges for the slope or intercept for a given WED error level. The variation of slope and intercept from different CT scanners of the same vendor introduced <±2.5% error in the estimated WED for subjects of 20 and 30‐cm WED. The calibration parameters remained stable over time, with the maximum deviations all within the boundary values that introduce ±2.5% error in the estimated WED for subjects of 20 and 30‐cm WED. Conclusions The stability in calibration results among CT scanners of the same vendor and over time demonstrated the feasibility of implementing WED estimation for routine clinical use.