Abstract
Background/Objectives: The Oncotype DX recurrence score (ODXRS) has emerged as an important tool for predicting recurrence risk and guiding treatment decisions in estrogen receptor-positive, human epidermal growth factor receptor 2-negative early-stage breast cancer. This review summarizes the current evidence on the clinical utility of the Oncotype DX RS and explores emerging research on potential imaging-based alternatives. The 21-gene assay provides a recurrence score that stratifies patients into low, intermediate, and high-risk groups, helping to identify patients who may benefit from adjuvant chemotherapy. Multiple validation studies have demonstrated the prognostic and predictive value of the ODXRS. However, the test is costly and requires tumor tissue samples. Methods: This paper systemically reviewed the current literature on the use of radiomic analysis of breast MRI to predict Oncotype DX. The literature search was performed from 2016 to 2024 using PubMed. We compared different image types, methods of analysis, sample size, numbers of high/intermediate and low scores, MRI image types, performance indices, among others. We also discussed lessons learned and suggested future research directions. Results: Recent studies have investigated the potential of radiomics applied to breast MRI to non-invasively predict the Oncotype DX RS. Quantitative imaging features extracted from dynamic contrast-enhanced MRI, diffusion-weighted imaging, and T2-weighted sequences have shown promise for distinguishing between low and high RS groups. Multiparametric MRI-based models integrating multiple sequences have achieved the highest performance. Conclusions: While further validation is needed, MRI radiomics may offer a non-invasive, cost-effective alternative for assessing recurrence risk.