The Role of Quantitative Ultrasound in Monitoring Neoadjuvant Chemotherapy in Breast Cancer: A Narrative Review

Breast cancer remains the most commonly diagnosed malignancy and a leading cause of cancer-related mortality among women worldwide. Neoadjuvant chemotherapy (NAC) is increasingly used, particularly in aggressive subtypes such as HER2-positive and triple-negative breast cancer, where achieving a pathological complete response (pCR) is strongly associated with improved outcomes. Early and accurate assessment of therapeutic response is therefore essential to enable timely treatment adaptation. Conventional imaging methods-including magnetic resonance imaging (MRI), computed tomography (CT), mammography, and B-mode ultrasound-mainly detect macroscopic tumor shrinkage and often lagging behind biological alterations, as they rely primarily on size-based assessment. Quantitative ultrasound (QUS) is an emerging, non-invasive technique that analyzes raw radiofrequency (RF) ultrasound data to extract spectral, scattering, and attenuation parameters, allowing detailed characterization of tumor microstructure. When combined with parametric mapping, texture analysis, and advanced radiomic or deep learning approaches, QUS can capture subtle tissue alterations at an early stage of therapy and help predict pathological response before conventional imaging detects morphologic change. Integration with molecular and clinical data further enhances predictive performance, enabling adaptive and personalized treatment strategies. This narrative review summarizes current evidence on the clinical utility of QUS in monitoring NAC response in breast cancer, outlines the methodological foundations of this technology, and discusses key challenges to its broader implementation-particularly the need for standardized acquisition and processing protocols, robust interpretive algorithms and large, prospective, multicenter validations to confirm its impact on clinical decision-making and patient outcomes, and to accelerate its translation into precision oncology practice.