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Clumped and Clustered Ring Enhancement (MR)
Katie M. Davis, DO; Wendie A. Berg, MD, PhD, FACR, FSBI
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          TERMINOLOGY

          • Synonyms

            • Cobblestone, beaded, string of pearls, bunch of grapes
          • Definitions

            • Focus: Tiny dot of enhancement too small to be space occupying (i.e., not mass); shape and margins cannot be described; ≤ 4 mm
            • Nonmass enhancement (NME): Neither focus nor mass, not space occupying
            • Internal enhancement patterns of NME: Clumped, clustered ring
              • Clumped: Aggregate of foci or small, nodular areas
              • Clustered ring: Periductal enhancement related to contrast pooling in periductal stroma
              • Both clumped and clustered ring enhancement are strong indicators of malignancy and often coexist
            • Consider NME distribution
              • Focal: < volume of quadrant, fat or fibroglandular tissue interspersed between abnormality
              • Linear: Arranged in line or line that branches, suggests ductal distribution
              • Segmental: Cone of enhancement with apex pointing toward nipple
              • Regional: Large geographic area > 1 quadrant, not conforming to 1 ductal distribution
            • DCIS: Proliferation of malignant epithelial cells that line terminal ductal-lobular unit without invasion of basement membrane

          IMAGING

          • General Features

            • Imaging Recommendations

              • Image-Guided Biopsy

                DIFFERENTIAL DIAGNOSIS

                  PATHOLOGY

                  • General Features

                    • Microscopic Features

                      CLINICAL ISSUES

                      • Demographics

                        • Natural History & Prognosis

                          • Treatment

                            DIAGNOSTIC CHECKLIST

                            • Image Interpretation Pearls

                              Selected References

                              1. Lee SM et al: Patterns of malignant non-mass enhancement on 3-T breast MRI help predict invasiveness: using the BI-RADS lexicon fifth edition. Acta Radiol. 59(11):1292-9, 2018
                              2. Chikarmane SA et al: Revisiting nonmass enhancement in breast MRI: analysis of outcomes and follow-up using the updated BI-RADS atlas. AJR Am J Roentgenol. 209(5):1178-84, 2017
                              3. Chu AN et al: Magnetic resonance imaging characteristics of granulomatous mastitis. Clin Imaging. 43:199-201, 2017
                              4. Milosevic ZC et al: Breast dynamic contrast enhanced MRI: fibrocystic changes presenting as a non-mass enhancement mimicking malignancy. Radiol Oncol. 51(2):130-6, 2017
                              5. Machida Y et al: Descriptors of malignant non-mass enhancement of breast MRI: their correlation to the presence of invasion. Acad Radiol. 23(6):687-95, 2016
                              6. Shimauchi A et al: Morphology evaluation of nonmass enhancement on breast MRI: Effect of a three-step interpretation model for readers' performances and biopsy recommendations. Eur J Radiol. 85(2):480-8, 2016
                              7. Morris EA, Comstock CE, Lee CH, et al. ACR BI-RADS® Magnetic Resonance Imaging. In: ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology; 2013.
                              8. Greenwood HI et al: Ductal carcinoma in situ of the breasts: review of MR imaging features. Radiographics. 33(6):1569-88, 2013
                              9. Uematsu T et al: High-spatial-resolution 3-T breast MRI of nonmasslike enhancement lesions: an analysis of their features as significant predictors of malignancy. AJR Am J Roentgenol. 198(5):1223-30, 2012
                              10. Wilhelm A et al: Malignancy rates of non-masslike enhancement on breast magnetic resonance imaging using American College of Radiology Breast Imaging Reporting and Data System descriptors. Breast J. 18(6):523-6, 2012
                              11. Kim JA et al: MRI findings of pure ductal carcinoma in situ: kinetic characteristics compared according to lesion type and histopathologic factors. AJR Am J Roentgenol. 196(6):1450-6, 2011
                              12. Abe H et al: MR-directed ("Second-Look") ultrasound examination for breast lesions detected initially on MRI: MR and sonographic findings. AJR Am J Roentgenol. 194(2):370-7, 2010
                              13. Jones KN et al: Pseudoangiomatous stromal hyperplasia: imaging findings with pathologic and clinical correlation. AJR Am J Roentgenol. 195(4):1036-42, 2010
                              14. Mossa-Basha M et al: Ductal carcinoma in situ of the breast: MR imaging findings with histopathologic correlation. Radiographics. 30:1673-87, 2010
                              15. Yamada T et al: Radiologic-pathologic correlation of ductal carcinoma in situ. Radiographics. 30(5):1183-98, 2010
                              16. Demartini WB et al: Utility of targeted sonography for breast lesions that were suspicious on MRI. AJR Am J Roentgenol. 192(4):1128-34, 2009
                              17. Meissnitzer M et al: Targeted ultrasound of the breast in women with abnormal MRI findings for whom biopsy has been recommended. AJR Am J Roentgenol. 193(4):1025-9, 2009
                              18. Raza S et al: Pure ductal carcinoma in situ: a range of MRI features. AJR Am J Roentgenol. 191(3):689-99, 2008
                              19. Kuhl CK et al: MRI for diagnosis of pure ductal carcinoma in situ: a prospective observational study. Lancet. 370(9586):485-92, 2007
                              20. Macura KJ et al: Patterns of enhancement on breast MR images: interpretation and imaging pitfalls. Radiographics. 26(6):1719-34; quiz 1719, 2006
                              21. Morakkabati-Spitz N et al: Diagnostic usefulness of segmental and linear enhancement in dynamic breast MRI. Eur Radiol. 15(9):2010-7, 2005
                              22. Liberman L et al: Ductal enhancement on MR imaging of the breast. AJR Am J Roentgenol. 181(2):519-25, 2003
                              23. Nakahara H et al: A comparison of MR imaging, galactography and ultrasonography in patients with nipple discharge. Breast Cancer. 10(4):320-9, 2003
                              24. Neubauer H et al: High grade and non-high grade ductal carcinoma in situ on dynamic MR mammography: characteristic findings for signal increase and morphological pattern of enhancement. Br J Radiol. 76(901):3-12, 2003
                              25. Tuncbilek N et al: Evaluation of tumor angiogenesis with contrast-enhanced dynamic magnetic resonance mammography. Breast J. 9(5):403-8, 2003
                              26. Liberman L et al: Breast lesions detected on MR imaging: features and positive predictive value. AJR Am J Roentgenol. 179(1):171-8, 2002
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Imaging

                                  • Top Differential Diagnoses

                                    • Clinical Issues

                                      TERMINOLOGY

                                      • Synonyms

                                        • Cobblestone, beaded, string of pearls, bunch of grapes
                                      • Definitions

                                        • Focus: Tiny dot of enhancement too small to be space occupying (i.e., not mass); shape and margins cannot be described; ≤ 4 mm
                                        • Nonmass enhancement (NME): Neither focus nor mass, not space occupying
                                        • Internal enhancement patterns of NME: Clumped, clustered ring
                                          • Clumped: Aggregate of foci or small, nodular areas
                                          • Clustered ring: Periductal enhancement related to contrast pooling in periductal stroma
                                          • Both clumped and clustered ring enhancement are strong indicators of malignancy and often coexist
                                        • Consider NME distribution
                                          • Focal: < volume of quadrant, fat or fibroglandular tissue interspersed between abnormality
                                          • Linear: Arranged in line or line that branches, suggests ductal distribution
                                          • Segmental: Cone of enhancement with apex pointing toward nipple
                                          • Regional: Large geographic area > 1 quadrant, not conforming to 1 ductal distribution
                                        • DCIS: Proliferation of malignant epithelial cells that line terminal ductal-lobular unit without invasion of basement membrane

                                      IMAGING

                                      • General Features

                                        • Imaging Recommendations

                                          • Image-Guided Biopsy

                                            DIFFERENTIAL DIAGNOSIS

                                              PATHOLOGY

                                              • General Features

                                                • Microscopic Features

                                                  CLINICAL ISSUES

                                                  • Demographics

                                                    • Natural History & Prognosis

                                                      • Treatment

                                                        DIAGNOSTIC CHECKLIST

                                                        • Image Interpretation Pearls

                                                          Selected References

                                                          1. Lee SM et al: Patterns of malignant non-mass enhancement on 3-T breast MRI help predict invasiveness: using the BI-RADS lexicon fifth edition. Acta Radiol. 59(11):1292-9, 2018
                                                          2. Chikarmane SA et al: Revisiting nonmass enhancement in breast MRI: analysis of outcomes and follow-up using the updated BI-RADS atlas. AJR Am J Roentgenol. 209(5):1178-84, 2017
                                                          3. Chu AN et al: Magnetic resonance imaging characteristics of granulomatous mastitis. Clin Imaging. 43:199-201, 2017
                                                          4. Milosevic ZC et al: Breast dynamic contrast enhanced MRI: fibrocystic changes presenting as a non-mass enhancement mimicking malignancy. Radiol Oncol. 51(2):130-6, 2017
                                                          5. Machida Y et al: Descriptors of malignant non-mass enhancement of breast MRI: their correlation to the presence of invasion. Acad Radiol. 23(6):687-95, 2016
                                                          6. Shimauchi A et al: Morphology evaluation of nonmass enhancement on breast MRI: Effect of a three-step interpretation model for readers' performances and biopsy recommendations. Eur J Radiol. 85(2):480-8, 2016
                                                          7. Morris EA, Comstock CE, Lee CH, et al. ACR BI-RADS® Magnetic Resonance Imaging. In: ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology; 2013.
                                                          8. Greenwood HI et al: Ductal carcinoma in situ of the breasts: review of MR imaging features. Radiographics. 33(6):1569-88, 2013
                                                          9. Uematsu T et al: High-spatial-resolution 3-T breast MRI of nonmasslike enhancement lesions: an analysis of their features as significant predictors of malignancy. AJR Am J Roentgenol. 198(5):1223-30, 2012
                                                          10. Wilhelm A et al: Malignancy rates of non-masslike enhancement on breast magnetic resonance imaging using American College of Radiology Breast Imaging Reporting and Data System descriptors. Breast J. 18(6):523-6, 2012
                                                          11. Kim JA et al: MRI findings of pure ductal carcinoma in situ: kinetic characteristics compared according to lesion type and histopathologic factors. AJR Am J Roentgenol. 196(6):1450-6, 2011
                                                          12. Abe H et al: MR-directed ("Second-Look") ultrasound examination for breast lesions detected initially on MRI: MR and sonographic findings. AJR Am J Roentgenol. 194(2):370-7, 2010
                                                          13. Jones KN et al: Pseudoangiomatous stromal hyperplasia: imaging findings with pathologic and clinical correlation. AJR Am J Roentgenol. 195(4):1036-42, 2010
                                                          14. Mossa-Basha M et al: Ductal carcinoma in situ of the breast: MR imaging findings with histopathologic correlation. Radiographics. 30:1673-87, 2010
                                                          15. Yamada T et al: Radiologic-pathologic correlation of ductal carcinoma in situ. Radiographics. 30(5):1183-98, 2010
                                                          16. Demartini WB et al: Utility of targeted sonography for breast lesions that were suspicious on MRI. AJR Am J Roentgenol. 192(4):1128-34, 2009
                                                          17. Meissnitzer M et al: Targeted ultrasound of the breast in women with abnormal MRI findings for whom biopsy has been recommended. AJR Am J Roentgenol. 193(4):1025-9, 2009
                                                          18. Raza S et al: Pure ductal carcinoma in situ: a range of MRI features. AJR Am J Roentgenol. 191(3):689-99, 2008
                                                          19. Kuhl CK et al: MRI for diagnosis of pure ductal carcinoma in situ: a prospective observational study. Lancet. 370(9586):485-92, 2007
                                                          20. Macura KJ et al: Patterns of enhancement on breast MR images: interpretation and imaging pitfalls. Radiographics. 26(6):1719-34; quiz 1719, 2006
                                                          21. Morakkabati-Spitz N et al: Diagnostic usefulness of segmental and linear enhancement in dynamic breast MRI. Eur Radiol. 15(9):2010-7, 2005
                                                          22. Liberman L et al: Ductal enhancement on MR imaging of the breast. AJR Am J Roentgenol. 181(2):519-25, 2003
                                                          23. Nakahara H et al: A comparison of MR imaging, galactography and ultrasonography in patients with nipple discharge. Breast Cancer. 10(4):320-9, 2003
                                                          24. Neubauer H et al: High grade and non-high grade ductal carcinoma in situ on dynamic MR mammography: characteristic findings for signal increase and morphological pattern of enhancement. Br J Radiol. 76(901):3-12, 2003
                                                          25. Tuncbilek N et al: Evaluation of tumor angiogenesis with contrast-enhanced dynamic magnetic resonance mammography. Breast J. 9(5):403-8, 2003
                                                          26. Liberman L et al: Breast lesions detected on MR imaging: features and positive predictive value. AJR Am J Roentgenol. 179(1):171-8, 2002