Abstract
BACKGROUND: Traditional immunohistochemistry assessment of Ki-67 in breast cancer (BC) via core needle biopsy is invasive, inaccurate, and nonrepeatable. While machine learning (ML) provides a promising alternative, its effectiveness depends on extensive data. Although the current mainstream MRI-centered radiomics offers sufficient data, its unsuitability for repeated examinations, along with limited accessibility and an intratumoral focus, constrain the application of predictive models in evaluating Ki-67 levels. OBJECTIVE: This study aims to explore ultrasound (US) image-based radiomics, incorporating both intra- and peritumoral features, to develop an interpretable ML model for predicting Ki-67 expression in BC patients. METHODS: A retrospective analysis was conducted on 263 BC patients, divided into training and external validation cohorts. From intratumoral and peritumoral regions of interest (ROIs) in US images, 849 distinctive radiomics features per ROI were derived. These features underwent systematic selection to analyze Ki-67 expression relationships. Four ML models-logistic regression, random forests, support vector machine (SVM), and extreme gradient boosting-were formulated and internally validated to identify the optimal predictive model. External validation was executed to ascertain the robustness of the optimal model, followed by employing Shapley Additive Explanations (SHAP) to reveal the significant features of the model. RESULTS: Among 231 selected BC patients, 67.5% exhibited high Ki-67 expression, with consistency observed across both training and validation cohorts as well as other clinical characteristics. Of the 1698 radiomics features identified, 15 were significantly correlated with Ki-67 expression. The SVM model, utilizing combined ROI, demonstrated the highest accuracy [area under the receiver operating characteristic curve (AUROC): 0.88], making it the most suitable for predicting Ki-67 expression. External validation sustained an AUROC of 0.82, affirming the model's robustness above a 40% threshold. SHAP analysis identified five influential features from intra- and peritumoral ROIs, offering insight into individual prediction. CONCLUSION: This study emphasized the potential of SVM model using radiomics features from both intra- and peritumoral US images, for predicting elevated Ki-67 levels in BC patients. The model exhibited strong performance in validations, indicating its promise as a noninvasive tool to enable personalized decision-making in BC care.