Abstract Background: Locally advanced breast cancer is defined as breast cancer with large tumor size (T2 or higher stage), high regional lymph node burden, or direct invasion of the skin or underlying chest wall. Neoadjuvant chemotherapy (NAC) is the standard care option for locally advanced breast cancer patients. Quantification of echogenic changes can predict pCR of breast cancer lesions after NAC. Aim of Study: To investigate the role of change in echo-genicity at the B mode ultrasound in the assessment of response in breast cancer patients after neoadjuvant chemotherapy administration. Patient and Methods: We did 192 ultrasound examinations for the 48 cases as they were examined before pretreatment, post-first cycle, post-second cycle of chemotherapy then post fourth cycle. The correlation of response to chemotherapy was done by pathological examination of the postoperative specimen. Grading on response was based on RCB (residual cancer burden). Results: The cases with complete pathological response pCR were (22 cases) 45.8% and those who could not achieve complete pathological response (26 cases) 55.2%. The change in echogenicity could predict response to treatment as early as first cycle (p-value=0.012). Conclusion: The breast cancer echogenicity can predict p CR in cases of breast cancer in neoadjuvant status as early as first cycle. Hence, we recommend using of lesions echo-genicity to predict pCR and to monitor response to neoadjuvant chemotherapy. Further interventional studies are needed to modify the treatment plan according to the predicted response by the US as early as the first cycle.