Background <p>To investigate whether kinetic heterogeneity, assessed via dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI)-based radiomics nomogram, associated with axillary lymph node metastasis (ALNM) in cN0 breast cancer.</p> Methods <p>524 consecutive women with cN0 breast cancer who underwent preoperative DCE-MRI were retrospectively evaluated from 2016 to 2022. The kinetic heterogeneity (a measure of heterogeneity in the proportions of peak enhancement, peak enhancement ratio, persistent, plateau, and washout) was assessed with DCE-MRI using B.K. software automatically. Radiomics features were extracted from magnetic resonance imaging (MRI) images of the primary breast cancer lesion. The minimum redundancy maximum relevance algorithm was used to select ALNM positively-related features and radiomics score was constructed. Clinical features, MRI features, kinetic heterogeneity, and radiomics score were screened out by multivariate logistic regression analysis, and the nomogram was constructed from these characteristics. Possible associations between DCE-MRI-based kinetic heterogeneity and ALNM were analyzed. The unsupervised clustering K-Mean algorithm was use to risk stratification.</p> Results <p>Five independent risk factors were screened out to build the nomogram, including: age, margin, ratio, washout, and radiomics score. The area under the receiver operating characteristic curve was 0.879 and 0.816 in the training and test cohorts, respectively. The risk stratification system divided all patients into three risk groups. Axillary lymph node dissection was not recommended for the low-risk group and was strongly recommended for the high-risk group.</p> Conclusions <p>Radiomic analysis of kinetic heterogeneity based on the DCE-MRI images has the potential to more accurately identify tumor kinetic features and serve as a valuable clinical marker to enhance the prediction of ALNM in cN0 breast cancer.</p>