Purpose: Neoadjuvant systemic treatment (NST) elicits a pathologic complete response in 40%-70% of women with breast cancer. These patients may not need surgery as all local tumor has already been eradicated by NST. However, nonsurgical approaches, including imaging or vacuum-assisted biopsy (VAB), were not able to accurately identify patients without residual cancer in the breast or axilla. We evaluated the feasibility of a machine learning algorithm (intelligent VAB) to identify exceptional responders to NST., Methods: We trained, tested, and validated a machine learning algorithm using patient, imaging, tumor, and VAB variables to detect residual cancer after NST (ypT+ or in situ or ypN+) before surgery. We used data from 318 women with cT1-3, cN0 or +, human epidermal growth factor receptor 2-positive, triple-negative, or high-proliferative Luminal B-like breast cancer who underwent VAB before surgery (ClinicalTrials.gov identifier: NCT02948764, RESPONDER trial). We used 10-fold cross-validation to train and test the algorithm, which was then externally validated using data of an independent trial (ClinicalTrials.gov identifier: NCT02575612). We compared findings with the histopathologic evaluation of the surgical specimen. We considered false-negative rate (FNR) and specificity to be the main outcomes., Results: In the development set (n = 318) and external validation set (n = 45), the intelligent VAB showed an FNR of 0.0%-5.2%, a specificity of 37.5%-40.0%, and an area under the receiver operating characteristic curve of 0.91-0.92 to detect residual cancer (ypT+ or in situ or ypN+) after NST. Spiegelhalter's Z confirmed a well-calibrated model ( z score -0.746, P = .228). FNR of the intelligent VAB was lower compared with imaging after NST, VAB alone, or combinations of both., Conclusion: An intelligent VAB algorithm can reliably exclude residual cancer after NST. The omission of breast and axillary surgery for these exceptional responders may be evaluated in future trials., Competing Interests: Geraldine RauchHonoraria: AbbVie Bettina ThomasHonoraria: Bayer/Vital (I), Boehringer Ingelheim (I), Bristol Myers Squibb (I), Medtronic (I), Pfizer (I), Daiichi Sankyo (I), Sanofi (I), St Jude Medical (I), ZOLL CMS (I)Consulting or Advisory Role: Pfizer (I), Bayer/Vital (I)Research Funding: Daiichi Sankyo (I)Patents, Royalties, Other Intellectual Property: Method and kit for assessment of sodium-channel related anti- or pro-arrhythmic potential of compounds, EU, No. EP14181787.4 (I); KCNK3-Based Gene Therapy of Cardiac Arrhythmia, EU, No. EP18793590.3 and US, 20-539-PCT-US (I); Task 1 Inhibitors for Treatment of Atrial Arrhythmias, China, 201980053974.7, US, US-2021-0308103-A1, and EU, EP2019/071858 (I) Sherko KuemmelConsulting or Advisory Role: Roche/Genentech, Genomic Health, Novartis, AstraZeneca, Amgen, Celgene, SOMATEX, Daiichi Sankyo, pfm medical, Pfizer, MSD Oncology, Lilly, SonoScape, Gilead Sciences, Seattle Genetics, AgendiaTravel, Accommodations, Expenses: Roche, Daiichi Sankyo, SonoScapeUncompensated Relationships: West German Study Group Toralf ReimerConsulting or Advisory Role: PfizerResearch Funding: Else Kröner-Fresenius-Stiftung, German Cancer AidOther Relationship: Pfizer Marc ThillHonoraria: Amgen, AstraZeneca/Daiichi Sankyo, Clovis Oncology, ClearCut Medical, Daiichi Sankyo Europe GmbH, Eisai Germany, Exact Sciences, Lilly, MSD Oncology, Novartis, Pfizer, pfm medical, Roche, Seattle Genetics, Seattle Genetics, Sysmex, Servier/PfizerConsulting or Advisory Role: Amgen, AstraZeneca, ClearCut, Clovis Oncology, Becton/Dickinson, Biom'Up, Daiichi Sankyo/Astra Zeneca, Exact Sciences, Gilead Sciences, Lilly, MSD Oncology, Neodynamics, Novartis, Pfizer, pfm medical, Pierre Fabre, Roche, Seattle Genetics, SysmexResearch Funding: Exact Sciences (Inst), Endomag (Inst)Expert Testimony: pfm medicalTravel, Accommodations, Expenses: ClearCut Medical, Roche, pfm medical, Pfizer, Lilly Jens-Uwe BlohmerHonoraria: Amgen, AstraZeneca, MSD Oncology, Novartis, Pfizer, Roche, Lilly, Gilead Sciences, Eisai Germany, Seattle Genetics, Daiichi Sankyo/Astra Zeneca, Exact Sciences, Molecular HealthConsulting or Advisory Role: Amgen, AstraZeneca, Novartis, Pfizer, RocheTravel, Accommodations, Expenses: Pfizer, Roche Wolfram MalterHonoraria: RocheConsulting or Advisory Role: PfizerTravel, Accommodations, Expenses: Celgene, Novartis Stefan PaepkeHonoraria: Grünenthal, Sysmex GmBH Deutschland, Endomag, Cambridge UK, pfm medical ag, KölnConsulting or Advisory Role: Grünenthal, Sysmex GmBH Deutschland, Endomag, Cambridge UK, pfm medical ag, Köln, Deutschland, Invitrocue Europe GmBH, Becton & DickinsonSpeakers’ Bureau: Grünenthal, Sysmex GmBH Deutschland, Endomag, Cambridge UK, pfm medical ag, Köln, Deutschland, Invitrocue Europe GmBH, Becton & Dickinson, Neodynamics, SchwedenTravel, Accommodations, Expenses: Grünenthal, Invitrocue Europe, Endomag Cambridge UK, Medtronic, Neodynamics, Novus scientific, pfm medical, Sysmex und Roche Tom DegenhardtHonoraria: PfizerConsulting or Advisory Role: Roche/GenentechResearch Funding: Pfizer (Inst)Travel, Accommodations, Expenses: Daiichi Sankyo, Tesaro Joachim RomConsulting or Advisory Role: AstraZeneca, Corza Medical, Exact Sciences, Johnson & Johnson/Janssen, LEO Pharma, Roche Pharma AG, Jörg Eickeler, Meet the Experts Academy Achim RodyHonoraria: Roche, Pfizer, Novartis, Celgen, Novartis, Exact Sciences, MSD, Pierre Fabre, Lilly, Seagen, TargosConsulting or Advisory Role: Roche, Astra Zeneca, Pfizer, Celgen, Eisai, Novartis, MSD, Hexal, Amgen, Exact Sciences, Pierre Fabre Marion van MackelenberghHonoraria: Amgen, AstraZeneca/Daiichi Sankyo, GlaxoSmithKline, Lilly, Molecular Health, Mylan, Novartis, Pfizer, Pierre Fabre, Roche, Seattle Genetics, Gilead SciencesConsulting or Advisory Role: Amgen, AstraZeneca/Daiichi Sankyo, Genomic Health, Gilead Sciences, GlaxoSmithKline, Lilly, Molecular Health, Molecular Health, Mylan, Novartis, Pfizer, Pierre Fabre, Roche, Seattle GeneticsTravel, Accommodations, Expenses: Daiichi Sankyo Europe GmbH, Lilly Maggie Banys-PaluchowskiConsulting or Advisory Role: Novartis/Pfizer, Lilly, GlaxoSmithKline, Amgen, RocheSpeakers' Bureau: Novartis/Pfizer, Lilly, Seattle Genetics, Roche, pfm medicalResearch Funding: Exact Sciences, Endomagnetics (Inst), Merit Medical Systems (Inst), Mammotome (Inst) Mattea ReinischHonoraria: Pfizer, Novartis, Lilly, Roche Pharma AG, AstraZeneca, Daiichi Sankyo, SOMATEX, Seattle Genetics, PfizerConsulting or Advisory Role: Roche Pharma AG, Daiichi Sankyo, Hexal, Lilly, Novartis, Seattle Genetics, PfizerTravel, Accommodations, Expenses: Pfizer, Celgene, Novartis Maria KarstenEmployment: AstraZeneca, Roche Michael GolattaResearch Funding: Siemens Healthineers (Inst) Joerg HeilHonoraria: Roche, Siemens Healthcare Diagnostics, Bard MedicalConsulting or Advisory Role: Roche, Siemens Healthcare DiagnosticsResearch Funding: Bard MedicalTravel, Accommodations, Expenses: CelgeneNo other potential conflicts of interest were reported.