Deep clustering offers a promising approach for analyzing large unlabeled medical image datasets, yet prevailing methods still face two limitations: they may neglect class-agnostic structural priors that capture object boundaries and regions, and they do not explicitly encode topological patterns (e.g., connectivity and holes). These sources of information play distinct and complementary roles: visual-structural features provide the primary discriminative representation for clustering, while topological features provide additional global geometric cues for residual visual ambiguities. We introduce VTRL-Med, a progressive visual-structural learning framework with topology-guided regularization for medical image clustering. VTRL-Med first adapts the Segment Anything Model (SAM) to extract image features that retain structural cues inherited from mask-supervised pretraining. It then generates reliable pseudo-labels through a two-step filtering process that combines prototype-based selection with k-nearest neighbor consistency validation. Finally, it progressively refines the visual branch while an auxiliary topology branch, constructed from persistent homology (PH) descriptors, provides additional geometric regularization during training. Across 13 medical image benchmarks, VTRL-Med achieves state-of-the-art clustering performance, improving average accuracy by 4.48% over existing methods. On three representative datasets, topology-guided regularization further improves accuracy by 1.3--4.3% over visual refinement alone.

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