Treatments for Idiopathic Granulomatous Mastitis: Systematic Review and Meta-Analysis

Treatment Efficacy of Chuang Ling Ye, a Traditional Chinese Herbal Medicine Compound, on Idiopathic Granulomatous Mastitis: A Randomized Controlled Trial

Objective

To explore whether Chuang Ling Ye (CLY), a traditional Chinese herbal medicine compound, could improve the treatment of idiopathic granulomatous mastitis (IGM) via decreasing inflammatory response.

Methods

Herein, 40 patients with IGM who had wounds requiring dressing change were enrolled and randomly divided into two groups: the CLY group and the control group. The size of the neoplasm and pain score of patients were followed-up for 4 weeks. Local tissues were taken during dressing change and examined by commercial enzyme-linked immunosorbent assay (ELISA) kits. The levels of inflammatory markers, including interleukin-1β (IL-1β), IL-2, IL-6, interferon gamma (IFN-γ), and tumor necrosis factor-α (TNF-α) were measured.

Results

After treatment, the size of the neoplasm in the CLY group was significantly smaller than that in the control group (14.28 cm ± 8.96 cm vs. 21.14 cm ± 0.12 cm, P=0.038), and the pain scores were markedly reduced (P=0.004). Besides, CLY downregulated the expression levels of IL-1β, IFN-γ, and TNF-α.

Conclusion

External use of CLY could reduce the neoplasm of IGM by inhibiting local inflammation. This trial is registered with ChiCTR1800017744.

Factors associated with treatment duration and recurrence rate of complicated mastitis

BACKGROUND

The incidence of mastitis has increased, and this disease can lead to long antibiotic courses and complications. Here, we aimed to identify the factors associated with antibiotic duration and recurrence of complicated mastitis.

MATERIALS AND METHODS

This retrospective cohort study was conducted in a tertiary hospital in Taiwan. All hospitalized patients diagnosed with mastitis (ICD-9 code 611.0) from Jan. 1, 2012, to Dec. 31, 2016, were enrolled. Patient characteristics and clinical data were obtained from the medical charts. Recurrence was defined as mastitis within the first year after the discontinuation of antibiotics for at least 7 days.

RESULTS

In total, 214 females with a median age of 37 years old (IQR 33-45) were enrolled. A total of 148 patients (69.2%) underwent debridement, and 122 (57.0%) underwent biopsy. Histopathological examinations revealed granulation tissue in 44.6% (62/139) of the patients. Positive cultures were obtained in 65.9% (141/214) of the patients. Coagulase-negative staphylococci (64/141, 45.4%) was the most common pathogen, followed by Corynebacterium species (42/141, 29.8%). The median hospitalization length and antibiotic course were 7 (IQR 4-13) and 37 days (IQR 22-77), respectively. Three patients died of breast cancer during treatment. The recurrence rate was 18.5% (39/211). Younger age, corynebacterial infection, and pregnancy were associated with longer treatment durations (P < 0.001, 0.003, <0.001). Corynebacterial infection was associated with a 2.16-fold (95% CI: 1.11-4.20) increase in recurrence after adjusting for age.

CONCLUSION

Corynebacterial infection is associated with longer treatment courses and an increased recurrence rate of complicated mastitis. Therefore, specific treatments should be considered.

A systematic surgical approach for the treatment of idiopathic granulomatous mastitis: a case series

Background

Surgical resection can be performed for idiopathic granulomatous mastitis (IGM), but recurrence and tissue defects remain issues. Here we report our 6-year experience with a four-pattern surgical approach for IGM that involves the use of a random breast dermo-glandular flap (BDGF).

Methods

Sixty-eight consecutive patients with IGM were prospectively enrolled from 01/2012 and 03/2017. Based on the extent, shape, and location of the lesions, four different patterns of surgery based on BDGF were used to remove the lesion and repair the defect. Operative data (time, blood loss, and intraoperative complications), primary healing time, recurrence, and patient-reported outcomes (cosmetic outcome, and improvement in dressing change and bathing) at 2 years were evaluated.

Results

Patients' median age was 35 (range, 22-55) years. Duration of IGM was 3-22 months, with a median lesion size of 3.5 (range, 0.9-9.1) cm. The operative time was significantly longer, and blood loss was more important with the increasing lesion size (both P<0.05). No significant intraoperative complications occurred. All wounds healed by primary intention. IGM relapsed in three patients (3/68, 4.4%); they were treated successfully with a second operation. The self-evaluated cosmetic outcome was "much better" in 45 patients (66.2%), "a little better" in 18 (26.5%), and "same or worse" in five (7.3%). The self-evaluated improvement in dressing change and bathing was "improved a lot" in 51 patients (75.0%), "improved a little" in 11 (16.2%), and "not improved or getting worse" in six (8.8%).

Conclusions

The BDGF-based systematic four-pattern surgical approach is effective in the treatment of IGM. Recurrence rate is low, there are no complications, and the cosmetic results and improvement in dressing change and bathing are generally favourable.

Cystic neutrophilic granulomatous mastitis: an update

Cystic neutrophilic granulomatous mastitis (CNGM) is a rare subtype of granulomatous mastitis with a highly distinct histological pattern often associated with Corynebacterium species. CNGM is characterised by suppurative lipogranulomas that are composed of central lipid vacuoles rimmed by neutrophils and an outer cuff of epithelioid histiocytes. Some of the lipid vacuoles may contain sparse, rod-shaped, gram-positive bacilli that can be easily missed or dismissed. The surrounding mixed inflammatory infiltrate contains Langhans-type giant cells, lymphocytes and neutrophils. CNGM occurs in reproductive age women with a history of pregnancy and typically presents as a palpable mass that can be painful. CNGM has many mimickers, most significantly breast carcinoma. In many cases, CNGM has significant pathological and clinical overlap with other forms of granulomatous mastitis. Given the association with Corynebacterium species, early diagnosis of CNGM is essential in offering patients the most appropriate treatment. Prolonged antibiotic therapy specifically directed to corynebacteria is required, sometimes even beyond resolution of clinical symptoms. This comprehensive review of the existing literature on CNGM describes clinical-pathological features, microbiological findings, challenges associated with the microscopic differential diagnosis, clinical implications of this diagnosis and emerging treatment options. Morphological criteria and suggested comments to convey the degree of diagnostic certainty are also proposed for standard pathology reporting.

Different Treatments for Granulomatous Lobular Mastitis: A Systematic Review and Meta-Analysis

OBJECTIVE

Granulomatous lobular mastitis (GLM) is infrequently diagnosed. This study aimed to evaluate the efficacy and safety of managements for GLM in the nonlactation period.

METHODS

Publications were retrieved from PubMed, EMBASE, and the Cochrane library on September 10, 2018. We pooled and compared the outcome parameters and complete remission (CR) rates between different treatments using a meta-analysis.

RESULTS

Twenty-one publications including 970 patients treated with surgical excision, steroids, abscess drainage, antibiotics, and observation were included. Surgery significantly improved CR rate compared with steroids (p = 0.0003). There was no difference in the CR rate in patients treated with surgery alone or combined with steroids (p = 0.28). Surgery showed borderline significant efficacy in the CR rate compared with antibiotics (p = 0.06) and abscess drainage (p = 0.06). No difference was observed in effectiveness between observation and surgical management in patients diagnosed with early GLM and mild symptoms.

CONCLUSIONS

Although surgery was the ideal management for GLM, steroids and antibiotics might be ideal managements for GLM patients who are worried about surgical scars. Observation was an impressive alternative for patients with early GLM.

The Role of Establishing a Multidisciplinary Team for Idiopathic Granulomatous Mastitis in Improving Patient Outcomes and Spreading Awareness about Recent Disease Trends

Background

Iidiopathic granulomatous mastitis (IGM) is stereotypically described as a mysterious entity that mimics breast carcinoma imposing management challenges. In 2002, we established a multidisciplinary team to treat patients with IGM. This study aimed to evaluate the role of this team in improving patient outcomes. Also, a review of literature is provided to highlight recent disease trends. Patients and Methods. Pertinent data for 44 patients treated for IGM from 2002 to 2018 were analyzed and compared to data prior to 2002.

Results

Mean age at diagnosis was 37.9 years ± 6.4. The diagnosis of IGM was confirmed by True-cut biopsy (TCB), Frozen section (FS), and surgical biopsy in 70.5%, 25%, and 4.5% of patients, respectively. FS was used to assess the resection margins in three patients. Suspicion for malignancy was raised in one out of 39 ultrasound reports, and one out of 20 mammography reports. Wide local excision was the main treatment modality (95.5%). 19 patients (43.2%) received corticosteroids. Prior to 2002, IGM was only recognized after surgical resection with a 71% initial false impression of carcinoma. After 2002, the initial false clinical impression of carcinoma dropped to 29.5%. Recurrence rate was 31.82%. Younger age at diagnosis was significantly associated with recurrence (χ ² = 5.598; p = 0.018). Chi-square analysis showed no significant association between BMI and recurrence (χ ² = 0.776; p = 0.678).

Conclusion

The establishment of a multidisciplinary team for IGM was associated with a reduced erroneous impression of breast cancer, and a reduced false positive radiological diagnosis of breast carcinoma. FS was a useful confirmatory procedure. Our series included the first case of a diffuse papular rash as a systemic manifestation of IGM. Recent literature indicates that IGM is changing its face. IGM is being reported in all age groups, and even in males. The clinical manifestations have markedly expanded. Diagnosis by TCB has replaced blind surgical excision. More data regarding predictors of recurrence is accumulating.

The Predictive Value of the Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratio in Patients with Recurrent Idiopathic Granulomatous Mastitis

Objective

The aim of this study was to investigate the relationship between the inflammatory parameters including neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) and the prognosis of idiopathic granulomatous mastitis (IGM).

Materials and methods

In this retrospective study, a total of 41 patients with IGM who had no malignant disease or inflammatory pathologies were included between January 2010 and December 2017. The patients were divided into two groups according to presence or absence of recurrence. Subsequently, the relationship between patient characteristics, pre- and postoperative NLR and PLR levels and disease recurrence were evaluated.

Results

With a mean follow-up period of 28.4 months, 19.5% of patients were found to have recurrent IGM. Age, body mass index, patient characteristics such as oral contraceptive use, smoking status, and family history, surgical treatment and postoperative NLR, preoperative PLR, and postoperative PLR were not statistically significant between groups. However, only preoperative NLR was significantly associated with a recurrent IGM (p=0.024). Preoperative NLR predicted recurrence with a sensitivity of 62.5% and specificity of 84.8%.

Conclusion

These results demonstrated that a high level of NLR was predictive of poor outcome in patients with IGM.

Re-evaluating if observation continues to be the best management of idiopathic granulomatous mastitis

BACKGROUND

The presentation of idiopathic granulomatous mastitis can mimic breast cancer. Therefore, awareness of the condition is important for surgeons. The current series is the largest in a US population.

METHODS

Retrospective chart review of patients treated at a county, safety-net hospital in Arizona. Cases were identified from January 2006 to January 2019. Sociodemographic information, clinical history, management, and outcomes were collected.

RESULTS

There were 145 occurrences of idiopathic granulomatous mastitis among 120 women. Most of the patients (92%) were of Hispanic ethnicity and born outside (87%) of the United States. The average age was 35 years. Nearly all patients (95%) were parous, with an average of 3 pregnancies. Most (88%) presented with a palpable mass, and more than half (54%) of these masses were painful. Six patients had prolactinomas or hyperprolactinemia, 11 patients were pregnant, and 5 were postpartum. Early in the time period studied, 6 patients underwent excision of the masses. The remaining 114 underwent planned observation after biopsy confirmation of the diagnosis. Two patients were lost to follow-up, and the other 112 patients with idiopathic granulomatous mastitis resolved spontaneously. Nineteen had more than 1 episode. Average time to resolution was 5 months (range 0-20). Adjusted log-normal regression analysis found that later age of first live birth was associated with greater time to resolution (P < .01).

CONCLUSION

Idiopathic granulomatous mastitis is a self-limited, benign condition that waxes and wanes and eventually resolves without resection. After diagnosis, medications are unnecessary, and operations can be limited to drainage procedures for fluid collections.

A Proposal of a Clinically Based Classification for Idiopathic Granulomatous Mastitis

Objectives: There is no consensus regarding the surgical or immunosuppressive treatment of idiopathic granulomatous mastitis (IGM). This study aimed to introduce a clinical classification system for IGM that might facilitate its treatment and predict recurrence. Methods: We analyzed the management of 68 patients with IGM at (Princess Basma Teaching Hospital and King Abdulla University Hospital (1994-2016) to find out if distinct patterns of presentation exist according to the following parameters: presence of a painful or painless breast mass, local inflammation, abscess formation, communication to the skin, and extra-mammary manifestation. Results: We identified four distinct patterns of IGM: A: (13.23 %) A hard, painless breast mass. B: (52.94 %) A hard, painful breast mass with gross inflammation. C: (26.47 %) A breast abscess-like presentation. D: (7. 35 %) A subacute presentation with ulceration, sinus, or fistula formation. Erythema nodosum might complicate any of these patterns. Wide local excision in pattern A was curative with zero recurrence rate. The recurrence rates in patterns B and C were 22.20 % and 50.00 %. Patterns B, C, and D were treated by a combination of surgery and prednisolone. In keeping with this, recent literature is in favor of a wider use of immunosuppression especially in the presence of pus and extra-mammary findings. Conclusion: IGM could be classified into 4 distinct patterns according to the presenting signs and symptoms. These patterns correlated with treatment, recurrence rate, and the gross operative findings. This is the first step toward a classification for IGM. Multicenter and Meta-analysis studies are essential for a comprehensive prognostic classification. Treatment of IGM in any institution should be the responsibility of a multidisciplinary team.

Ductal Lavage for Patients With Nonlactational Mastitis: A Single-Arm, Proof-of-Concept Trial

BACKGROUND

Surgery, steroids, and/or observations alone have been proposed for patients with nonlactational mastitis (NLM), but most of these studies were retrospective. The optimal treatment for these patients remains unclear. This prospective, single-arm, proof-of-concept trial aimed to evaluate the feasibility and safety of ductal lavage as a novel treatment for patients with NLM.

METHODS

Eligible patients with NLM received an intraductal infusion of corticosteroids and antimicrobial agents and returned the next day for a breast massage. This cycle was repeated for 2 wk, and we followed up these patients for 1 y. Patients did not receive surgery or steroids after ductal lavage. The primary endpoint was the time to complete response (CR).

RESULTS

This trial included 32 patients with a median (range) age of 32 (20-53). Skin erythema and tenderness were the major symptoms. The median (range) visual analog score was 5 (0-9). There were 21 (65.6%), 4 (12.5%), and 7 (21.9%) patients diagnosed as idiopathic granulomatous mastitis, periductal mastitis, and unspecific NLM, respectively. During the ductal lavage, the median (range) number of cannulated ducts at first attempt was 5 (3-8). Ductal lavage significantly reduced the visual analog score and mastitis score (M-score) (P < 0.01). Within a median follow-up of 15.6 mo, 93.8% (30/32) of patients achieved CR. The median (range) time to CR was 6 (0.5-21) mo. Three patients (10.0%) relapsed. No adverse events associated with ductal lavage were observed.

CONCLUSIONS

Ductal lavage for patients with NLM is feasible and safe, and a definitive randomized controlled trial for further investigation is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02794688.

Granulomatous Mastitis: A Therapeutic and Diagnostic Challenge

Granulomatous mastitis (GM) is a rare benign inflammatory breast disease that affects mostly women of childbearing age with a history of breastfeeding. The etiopathogenesis is still unknown; however, inflammation as the result of a reaction to trauma, metabolic or hormonal processes, autoimmunity, and an infection with Corynebacterium kroppenstedtii have all been implicated. Clinical findings are pain, mass, hyperemia, and inflammation. Because the clinical presentation can mimic infectious mastitis or inflammatory carcinoma, the disease course is often protracted. The diagnosis is made by histopathology. Biopsies show a granulomatous formation in combination with a localized infiltration of multi-nucleated giant cells, epithelioid histiocytes, and plasma cells. Ultrasound, mammography, and magnetic resonance imaging are not specific; however, ultrasound and mammography should be done to exclude other pathologies. Due to the lack of data including randomized controlled studies, the management of GM is controversial. In Western industrialized countries, most authors use a therapy regimen starting with antibiotics and corticosteroids, followed by continuous steroid therapy and surgery in patients with persisting symptoms. More data are needed to define the best therapy. The role of immunotherapy has not yet been ascertained. The implementation of a registry to collect more information on this rare disease is highly recommended.

Granulomatous Lobular Mastitis: Antituberculous Treatment and Outcome in 22 Patients

Background

Granulomatous lobular mastitis (GLM) is a rare chronic inflammatory condition of the breast. The purpose of this study was to describe antituberculous treatment of GLM and the long-term follow-up outcome.

Methods

This retrospective study included 22 patients who had been histopathologically diagnosed with GLM at the Second Hospital of Shandong University from January 2011 to March 2015. Clinical characteristics, ultrasonography and mammography findings, laboratory tests, treatment regimens, follow-up information, and recurrences were recorded.

Results

All patients were female with a median age of 29 (range 23-44) years. The most common symptom was a breast mass with or without pain. Large irregular hypoechoic masses could be found in the breast ultrasounds of 13 patients. All patients received triple antituberculous therapy. During a median follow-up period of 40 months, 3 patients were lost to follow-up; of the remaining 19 patients, 18 achieved clinical complete remission and no recurrences were observed.

Conclusion

GLM is an unusual benign breast condition that mimics breast carcinoma in its clinical and imaging presentation. Antituberculous therapy seems to be an effective alternative option in the treatment of GLM.