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Focal Area, Regional, and Diffuse Enhancement (MR)
Becky Hwang, DO; Wendie A. Berg, MD, PhD, FACR, FSBI
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          TERMINOLOGY

          • Definitions

            • Nonmass enhancement (NME): MR enhancement distinct from parenchyma but not in mass or focus
            • Distribution types of NME: Focal area, regional, diffuse, linear, and segmental
            • Focal area: NME in confined area of breast; 5 mm up to < 25% of volume of quadrant
            • Regional: NME occupying large portion of breast tissue; ≥ 25% of 1 quadrant to > 1 quadrant; geographic
              • May show interspersed normal tissue; single or multiple regions of NME can be seen
            • Multiple regions: Enhancement in at least 2 large volumes of breast tissue separated by normal tissue; geographic and patchy
            • Diffuse: Enhancement throughout breast
            • Distinguish from linear and segmental distribution types
              • Linear: Enhancement in line that branches, suggests duct
              • Segmental: Triangular or cone-shaped enhancement with apex at nipple; suggests duct system and its branches (i.e., lobe or segment of breast)
            • Distinguish from focus: Tiny dot of enhancement (≤ 4 mm) too small to characterize shape or margins
            • Internal enhancement patterns of NME: Homogeneous or heterogeneous, clumped, clustered ring
              • Heterogeneous may have interspersed fat or normal glandular tissue
                • Clumped: Cobblestone, resembles bunch of grapes
                • Clustered ring: Thin rings of enhancement centered around ducts; enhancement in periductal stroma
            • Background parenchymal enhancement (BPE): Normal parenchymal enhancement can be misinterpreted as NME when presenting as large focal areas, multiple enhancing foci, or asymmetric enhancement

          IMAGING

          • General Features

            • Mammographic Findings

              • Ultrasonographic Findings

                • MR Findings

                  • Nuclear Medicine Findings

                    • Imaging Recommendations

                      • Image-Guided Biopsy

                        DIFFERENTIAL DIAGNOSIS

                          PATHOLOGY

                          • General Features

                            CLINICAL ISSUES

                            • Presentation

                              • Demographics

                                • Treatment

                                  DIAGNOSTIC CHECKLIST

                                  • Image Interpretation Pearls

                                    Selected References

                                    1. 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):1178-1184, 2017
                                    2. Song SE et al: Post-clip placement MRI following second-look US-guided core biopsy for suspicious lesions identified on breast MRI. Eur Radiol. 27(12):5196-203, 2017
                                    3. Milosevic ZC et al: Breast dynamic contrast enhanced MRI: Fibrocystic changes presenting as a non-mass enhancement mimicking malignancy. Radiol Oncol. 51(2):130-136, 2017
                                    4. Chadashvili T et al: Nonmass enhancement on breast MRI: review of patterns with radiologic-pathologic correlation and discussion of management. AJR Am J Roentgenol. 204(1):219-27, 2015
                                    5. Grimm LJ et al: Frequency of malignancy and imaging characteristics of probably benign lesions seen at breast MRI. AJR Am J Roentgenol. 205(2):442-7, 2015
                                    6. Hollowell L et al: Lesion morphology on breast MRI affects targeted ultrasound correlation rate. Eur Radiol. 25(5):1279-84, 2015
                                    7. Hsu HH et al. Breast nonmass enhancement detected with MRI: Uility and lesion characterization with second-look ultrasonography. Breast J. 21(6):579-87, 2015
                                    8. Morris EA et al: Breast Imaging Reporting and Data System, BI-RADS: Magnetic Resonance Imaging. 2nd ed. Reston: American College of Radiology, 2013
                                    9. Giess CS et al: Patterns of nonmasslike enhancement at screening breast MR imaging of high-risk premenopausal women. Radiographics. 33(5):1343-60, 2013
                                    10. Mahoney MC et al: Positive predictive value of BI-RADS MR imaging. Radiology. 264(1):51-8, 2012
                                    11. 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
                                    12. Baltzer PA et al: Nonmass lesions in magnetic resonance imaging of the breast: additional T2-weighted images improve diagnostic accuracy. J Comput Assist Tomogr. 35(3):361-6, 2011
                                    13. Demartini WB et al: Probability of malignancy for lesions detected on breast MRI: a predictive model incorporating BI-RADS imaging features and patient characteristics. Eur Radiol. 21(8):1609-17, 2011
                                    14. Jansen SA et al: The diverse pathology and kinetics of mass, nonmass, and focus enhancement on MR imaging of the breast. J Magn Reson Imaging. 33(6):1382-9, 2011
                                    15. Narayanan D et al: Interpretation of positron emission mammography: feature analysis and rates of malignancy. AJR Am J Roentgenol. 196:956-70; 2011
                                    16. 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. 194:370-7; 2010
                                    17. Baltzer PA et al: False-positive findings at contrast-enhanced breast MRI: a BI-RADS descriptor study. AJR Am J Roentgenol. 194(6):1658-63, 2010
                                    18. 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
                                    19. Gutierrez RL et al: BI-RADS lesion characteristics predict likelihood of malignancy in breast MRI for masses but not for nonmasslike enhancement. AJR Am J Roentgenol. 193:994-1000; 2009
                                    20. Gutierrez RL et al: Clinical indication and patient age predict likelihood of malignancy in suspicious breast MRI lesions. Acad Radiol. 16(10):1281-5, 2009
                                    21. 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. 193:1025-9; 2009
                                    22. Rosen EL, et al: BI-RADS MRI enhancement characteristics of ductal carcinoma in situ. Breast J. 13:545-50, 2007.
                                    23. Macura KJ et al: Patterns of enhancement on breast MR images: interpretation and imaging pitfalls. Radiographics. 26(6):1719-34; quiz 1719, 2006
                                    24. Schnall MD et al. Diagnostic architectural and dynamic features at breast MR imaging: multicenter study. Radiology. 238:42-53; 2006
                                    25. Liberman L et al: Breast lesions detected on MR imaging: Features and positive predictive value. AJR 179:171-178, 2002
                                    26. Nunes LW et al: Update of breast MR imaging architectural interpretation model. Radiology 219:484-94, 2001
                                    27. Kuhl CK et al: Healthy premenopausal breast parenchyma in dynamic contrast-enhanced MR imaging of the breast: normal contrast medium enhancement and cyclical-phase dependency. Radiology 203: 137-144; 1997
                                    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

                                            • Definitions

                                              • Nonmass enhancement (NME): MR enhancement distinct from parenchyma but not in mass or focus
                                              • Distribution types of NME: Focal area, regional, diffuse, linear, and segmental
                                              • Focal area: NME in confined area of breast; 5 mm up to < 25% of volume of quadrant
                                              • Regional: NME occupying large portion of breast tissue; ≥ 25% of 1 quadrant to > 1 quadrant; geographic
                                                • May show interspersed normal tissue; single or multiple regions of NME can be seen
                                              • Multiple regions: Enhancement in at least 2 large volumes of breast tissue separated by normal tissue; geographic and patchy
                                              • Diffuse: Enhancement throughout breast
                                              • Distinguish from linear and segmental distribution types
                                                • Linear: Enhancement in line that branches, suggests duct
                                                • Segmental: Triangular or cone-shaped enhancement with apex at nipple; suggests duct system and its branches (i.e., lobe or segment of breast)
                                              • Distinguish from focus: Tiny dot of enhancement (≤ 4 mm) too small to characterize shape or margins
                                              • Internal enhancement patterns of NME: Homogeneous or heterogeneous, clumped, clustered ring
                                                • Heterogeneous may have interspersed fat or normal glandular tissue
                                                  • Clumped: Cobblestone, resembles bunch of grapes
                                                  • Clustered ring: Thin rings of enhancement centered around ducts; enhancement in periductal stroma
                                              • Background parenchymal enhancement (BPE): Normal parenchymal enhancement can be misinterpreted as NME when presenting as large focal areas, multiple enhancing foci, or asymmetric enhancement

                                            IMAGING

                                            • General Features

                                              • Mammographic Findings

                                                • Ultrasonographic Findings

                                                  • MR Findings

                                                    • Nuclear Medicine Findings

                                                      • Imaging Recommendations

                                                        • Image-Guided Biopsy

                                                          DIFFERENTIAL DIAGNOSIS

                                                            PATHOLOGY

                                                            • General Features

                                                              CLINICAL ISSUES

                                                              • Presentation

                                                                • Demographics

                                                                  • Treatment

                                                                    DIAGNOSTIC CHECKLIST

                                                                    • Image Interpretation Pearls

                                                                      Selected References

                                                                      1. 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):1178-1184, 2017
                                                                      2. Song SE et al: Post-clip placement MRI following second-look US-guided core biopsy for suspicious lesions identified on breast MRI. Eur Radiol. 27(12):5196-203, 2017
                                                                      3. Milosevic ZC et al: Breast dynamic contrast enhanced MRI: Fibrocystic changes presenting as a non-mass enhancement mimicking malignancy. Radiol Oncol. 51(2):130-136, 2017
                                                                      4. Chadashvili T et al: Nonmass enhancement on breast MRI: review of patterns with radiologic-pathologic correlation and discussion of management. AJR Am J Roentgenol. 204(1):219-27, 2015
                                                                      5. Grimm LJ et al: Frequency of malignancy and imaging characteristics of probably benign lesions seen at breast MRI. AJR Am J Roentgenol. 205(2):442-7, 2015
                                                                      6. Hollowell L et al: Lesion morphology on breast MRI affects targeted ultrasound correlation rate. Eur Radiol. 25(5):1279-84, 2015
                                                                      7. Hsu HH et al. Breast nonmass enhancement detected with MRI: Uility and lesion characterization with second-look ultrasonography. Breast J. 21(6):579-87, 2015
                                                                      8. Morris EA et al: Breast Imaging Reporting and Data System, BI-RADS: Magnetic Resonance Imaging. 2nd ed. Reston: American College of Radiology, 2013
                                                                      9. Giess CS et al: Patterns of nonmasslike enhancement at screening breast MR imaging of high-risk premenopausal women. Radiographics. 33(5):1343-60, 2013
                                                                      10. Mahoney MC et al: Positive predictive value of BI-RADS MR imaging. Radiology. 264(1):51-8, 2012
                                                                      11. 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
                                                                      12. Baltzer PA et al: Nonmass lesions in magnetic resonance imaging of the breast: additional T2-weighted images improve diagnostic accuracy. J Comput Assist Tomogr. 35(3):361-6, 2011
                                                                      13. Demartini WB et al: Probability of malignancy for lesions detected on breast MRI: a predictive model incorporating BI-RADS imaging features and patient characteristics. Eur Radiol. 21(8):1609-17, 2011
                                                                      14. Jansen SA et al: The diverse pathology and kinetics of mass, nonmass, and focus enhancement on MR imaging of the breast. J Magn Reson Imaging. 33(6):1382-9, 2011
                                                                      15. Narayanan D et al: Interpretation of positron emission mammography: feature analysis and rates of malignancy. AJR Am J Roentgenol. 196:956-70; 2011
                                                                      16. 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. 194:370-7; 2010
                                                                      17. Baltzer PA et al: False-positive findings at contrast-enhanced breast MRI: a BI-RADS descriptor study. AJR Am J Roentgenol. 194(6):1658-63, 2010
                                                                      18. 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
                                                                      19. Gutierrez RL et al: BI-RADS lesion characteristics predict likelihood of malignancy in breast MRI for masses but not for nonmasslike enhancement. AJR Am J Roentgenol. 193:994-1000; 2009
                                                                      20. Gutierrez RL et al: Clinical indication and patient age predict likelihood of malignancy in suspicious breast MRI lesions. Acad Radiol. 16(10):1281-5, 2009
                                                                      21. 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. 193:1025-9; 2009
                                                                      22. Rosen EL, et al: BI-RADS MRI enhancement characteristics of ductal carcinoma in situ. Breast J. 13:545-50, 2007.
                                                                      23. Macura KJ et al: Patterns of enhancement on breast MR images: interpretation and imaging pitfalls. Radiographics. 26(6):1719-34; quiz 1719, 2006
                                                                      24. Schnall MD et al. Diagnostic architectural and dynamic features at breast MR imaging: multicenter study. Radiology. 238:42-53; 2006
                                                                      25. Liberman L et al: Breast lesions detected on MR imaging: Features and positive predictive value. AJR 179:171-178, 2002
                                                                      26. Nunes LW et al: Update of breast MR imaging architectural interpretation model. Radiology 219:484-94, 2001
                                                                      27. Kuhl CK et al: Healthy premenopausal breast parenchyma in dynamic contrast-enhanced MR imaging of the breast: normal contrast medium enhancement and cyclical-phase dependency. Radiology 203: 137-144; 1997