Abstract
Background: Response to neoadjuvant chemotherapy (NAC) is a key prognostic indicator in breast cancer, yet current assessment relies on postoperative pathology. This study investigated the use of deep features derived from pre-treatment MRI and CT scans, in conjunction with clinical variables, to predict treatment response a priori. Methods: Two response endpoints were analyzed: pathologic complete response (pCR) versus non-pCR, and responders versus non-responders, with response defined as a reduction in tumor size of at least 30%. Intratumoral and peritumoral segmentations were generated on contrast-enhanced T1-weighted (CE-T1) and T2-weighted MRI, as well as contrast-enhanced CT images of tumors. Deep features were extracted from these regions using ResNet10, ResNet18, ResNet34, and ResNet50 architectures pre-trained with MedicalNet. Handcrafted radiomic features were also extracted for comparison. Feature selection was conducted with minimum redundancy maximum relevance (mRMR) followed by recursive feature elimination (RFE), and classification was performed using XGBoost across ten independent data partitions. Results: A total of 177 patients were analyzed in this study. ResNet34-derived features achieved the highest overall classification performance under both criteria, outperforming handcrafted features and deep features from other ResNet architectures. For distinguishing pCR from non-pCR, ResNet34 achieved a balanced accuracy of 81.6%, whereas handcrafted radiomics achieved 77.9%. For distinguishing responders from non-responders, ResNet34 achieved a balanced accuracy of 73.5%, compared with 70.2% for handcrafted radiomics. Conclusions: Deep features extracted from routinely acquired MRI and CT, when combined with clinical information, improve the prediction of NAC response in breast cancer. This multimodal framework demonstrates the value of deep learning-based approaches as a complement to handcrafted radiomics and provides a basis for more individualized treatment strategies.