Phase-Dependent Transformation in NME: From Clumped to Clustered Ring on Breast MRI

Non-mass enhancement (NME) is a challenging entity in breast Magnetic Resonance Imaging (MRI) because of its heterogeneous morphology and high false-positive rate. Clustered ring enhancement (CRE) is recognized as a suspicious BI-RADS internal enhancement pattern; however, its phase-dependent depiction across dynamic acquisitions has not been systematically evaluated. This study aimed to investigate the association between phase-dependent appearance of CRE and malignancy in NME lesions and to assess the complementary role of diffusion-weighted imaging (DWI).

This retrospective single-center study included 80 patients (2022-2025), each with one histopathologically confirmed index NME lesion. Breast MRI was performed at 1.5 T using a dedicated breast coil and included early (0-2 min) and late (4-6 min) axial dynamic contrast-enhanced sequences, followed by a high-spatial-resolution sagittal post-contrast acquisition. DWI was obtained for apparent diffusion coefficient (ADC) analysis. Internal enhancement patterns were assessed across imaging phases by two breast radiologists blinded to histopathology. Statistical analysis included chi-square or Fisher's exact tests, receiver operating characteristic (ROC) analysis for ADC performance, and binary logistic regression.

Of the 80 lesions (median age, 46 years), 47 (58.8%) were benign and 33 (41.3%) malignant. Internal enhancement pattern on early dynamic images was not associated with malignancy. In contrast, CRE on late dynamic and high-spatial-resolution sagittal images showed a strong association with malignant pathology. Phase-dependent changes in internal enhancement appearance were observed in 43.8% of lesions, among which malignancy was more frequent. Washout kinetic curves were significantly more common in malignant lesions. ADC analysis demonstrated moderate diagnostic performance (AUC 0.745). Logistic regression identified CRE and increasing distribution extent as independent predictors of malignancy.

Phase-dependent appearance of CRE on later or high-spatial-resolution breast MRI acquisitions is associated with malignancy in NME lesions. Reliance on early dynamic imaging alone may underestimate this morphology. Late-phase and high-resolution post-contrast assessment may provide complementary morphological information for NME evaluation.