Pre-Treatment Breast MRI Features and ADC Values as Predictors of Pathologic Complete Response in Breast Cancer: A Molecular Subtype-Based Analysis

<b>Background/Objectives</b>: The role of pre-treatment breast magnetic resonance imaging (MRI) findings and apparent diffusion coefficient (ADC) values in predicting pathologic complete response (pCR) in breast cancer patients receiving neoadjuvant chemotherapy (NAC) has not yet been sufficiently clarified, especially in the context of molecular subtype differences. In this study, we questioned whether these imaging parameters were independent predictors of pCR. <b>Methods</b>: This study retrospectively explored MRI characteristics of 188 patients who underwent NAC from 2015 to 2023. The patients were divided into the pCR-positive and pCR-negative groups-the latter comprising patients with partial response (<i>n</i> = 61) and stable disease (<i>n</i> = 90)-and were classified into four molecular subtypes: Luminal A/B, HER2-enriched, and triple-negative breast cancer (TNBC). The MRI parameters included pre-chemotherapy T2-weighted signal characteristics, shape features, contrast kinetics, peritumoral edema, and ADC MIN/ADC MAX. Post-treatment ADC and ΔADC were the post-chemotherapy MRI parameters. Independent predictors were evaluated by logistic regression and discriminant performance by ROC analysis. <b>Results</b>: The overall pCR rate was 19.7%. In multivariate analysis, T2-weighted isointense signal (OR = 4.50), uniform tumor shape (OR = 12.83), HER2-enriched subtype (OR = 6.03), TNBC (OR = 5.15), ADC MIN (OR = 1.41), tumor size (OR = 1.28), and kinetic Type 3 pattern (OR = 3.21) were identified as independent predictors. Pre-treatment ADC MIN yielded an AUC of 0.724, while post-treatment ADC achieved 100% sensitivity and 96.7% specificity (AUC = 0.967). <b>Conclusions:</b> MRI morphology and ADC values may make a meaningful contribution to the prediction of pCR when evaluated in the context of molecular subtype. Post-treatment ADC demonstrated particularly strong discriminatory performance; however, external validation in multicenter cohorts is required before clinical implementation.