| Sumario: | Simple Summary: Neoadjuvant chemotherapy (NAC) is commonly used to reduce tumor burden in breast cancer prior to surgery. However, accurate prediction of therapeutic response remains a clinical challenge. In this study, we used breast MRI scans to analyze the number of blood vessels passing through the tumor at different stages of treatment (baseline, after two cycles of NAC and before surgery). Our results showed that patients with a greater reduction in tumor-associated blood vessels were more likely to achieve breast pathological complete response and longer relapse-free survival. Moreover, distinct vascular change patterns were correlated with different recurrence types. These findings suggest that MRI-derived vascular features may serve as non-invasive imaging biomarkers for predicting treatment efficacy and recurrence patterns, potentially guiding personalized therapeutic strategies for intensified post-NAC adjuvant therapy. Magnetic resonance imaging (MRI) is essential for assessing responses to neoadjuvant chemotherapy (NAC) in breast cancer. This exploratory analysis included 182 patients with locally advanced breast cancer who underwent MRI at baseline after two NAC cycles and post-treatment. Vessel-through-lesion (VTL) was quantified as the number of vessels passing through the lesion, with ΔVTL1-2 and ΔVTL1-3 representing relative VTL changes after the second and third MRI, respectively, compared to baseline. Patients were randomly divided into training and validation sets (7:3). A bpCR-predictive nomogram incorporating ΔVTL1-2 and clinicopathological factors out-performed a clinicopathology-only model (validation AUC of 0.892 vs. 0.857). Recurrence patterns differed by ΔVTL1-3 subgroup, where the low ΔVTL1-3 group showed an early recurrence peak within two years, while the high ΔVTL1-3 group maintained a stable, low recurrence risk over five years, particularly among non-pCR patients. The RFS-predictive nomogram using ΔVTL1-3 showed strong concordance with RFS (validation AUCs of 0.918 at 1 year, 0.767 at 3 years, and 0.717 at 5 years). Risk stratification showed superior RFS in the low-risk group. This study is the first to report that dynamic vascular evolution predicts bpCR and serves as an independent prognostic factor, associated with distinct recurrence patterns, particularly in non-pCR patients. These findings support early identification of patients for intensified post-NAC adjuvant therapy, enabling more precise treatment.
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