Vacuum-assisted biopsy and steroid therapy for granulomatous lobular mastitis: Report of three cases

Periductal Mastitis, a Disease with Distinct Clinicopathological Features from Granulomatous Lobular Mastitis

Purpose

Periductal mastitis (PDM) is a chronic inflammatory lesion of the breast with an unknown etiology, and it is difficult for clinicians to differentiate it from granulomatous lobular mastitis (GLM), although they have different treatment strategies and prognosis. This study aimed to investigate the differences in their clinicopathologic features to inform treatment strategies.

Patients and Methods

Between 2011 and 2020, 121 patients diagnosed with PDM and 57 patients with GLM were retrospective analysis. Patient data were extracted on demographics, clinical presentation, pathologic characteristics, treatments and clinical response. Histopathological evaluations were performed on core needle biopsy specimens. Immunohistochemical stains using antibodies against CD3, CD4, CD8, CD20, and CD138 was performed to define immune cell infiltration.

Results

PDM patients had a higher median age compared to GLM patients (38 vs 32, p<0.001). PDM was primarily located in the areolar area, while GLM predominantly affected the peripheral quadrant of the breast (56.20% vs 75.44%, p<0.001). Histopathologically, more ductal dilatation (90.08% vs 3.51%, p<0.001), ductal wall thickening (47.93% vs 1.75%, p<0.001), and ductal rupture (44.63% vs 5.26%, p<0.001) were observed in PDM. GLM presented with significantly more granuloma (94.74% vs 10.74%, p<0.001), microabscess (68.42% vs 28.93%, p<0.001), and lipid vacuole (40.35% vs 8.26%, p<0.001) formation than PDM. Immunohistochemical analysis revealed a significant presence of CD20+ B lymphocytes in PDM and a higher prevalence of CD8+ T lymphocytes in GLM, indicating differing immune responses. Treatment outcomes varied, with PDM patients responding well to surgery and anti-mycobacterial therapy, while GLM patients showed favorable responses to steroid therapy.

Conclusion

PDM is a specific entity with a similar clinical presentation but distinct histopathological features and immune profiles to GLM. Further research is needed to elucidate the pathogenesis and optimize therapeutic approaches for these breast inflammatory conditions.

Efficacy and safety of rifampicin-based triple therapy for non-puerperal mastitis: A single-arm, open-label, prospective clinical trial

OBJECTIVES

To assess the efficacy and safety of rifampicin-based triple therapy (rifampicin, isoniazid, and ethambutol) for treating NPM.

METHODS

This single-center, single-arm, prospective clinical trial was conducted at the Second Hospital of Shandong University (Jinan, China). Patients with pathologically diagnosed granulomatous lobular mastitis and periductal mastitis received triple drugs, i.e., rifampicin (450 mg/day), isoniazid (300 mg/day), and ethambutol (15 mg/kg/day), until complete response or the investigator decided to discontinue treatment. The primary endpoint was the complete response rate (CRR) assessed by the investigator. The secondary endpoints included the overall remission rate (ORR), recurrence rate (RR), and safety.

RESULTS

A total of 218 patients were enrolled in the study between January 1, 2013 and October 31, 2020. With a median follow-up time of 48 months, the CRR and the ORR were 78.44% and 94.04%, respectively. While 13 patients (5.96%) demonstrated no response and 19 relapsed (8.72%). Adverse events (AEs) were not common. The most common AEs during treatment were liver dysfunction (1.83%), gastrointestinal reactions (1.83%), fatigue (1.83%), erythema (1.38%), and menstrual disorders (0.92%).

CONCLUSION

Rifampicin, isoniazid, and ethambutol demonstrated promising response rates with acceptable safety profiles in patients with NPM. Further confirmatory trial is warranted in the future.

TRIAL REGISTRATION

The study was approved by the Ethics Committee of the Second Hospital of Shandong University and retrospectively registered at the China Clinical Trial Registration Center (registration number: ChiCTR2100049591).

The Disease Experience of Women with Granulomatous Lobular Mastitis. A Qualitative Interview Study

Background

The incidence of granulomatous lobular mastitis (GLM) is increasing year by year, and the breast wounds of women patients with GLM can develop into abscesses, fistulas, sinuses, and sometimes orange-like degeneration similar to malignant tumors, which seriously affects the quality of life of women patients with GLM. In China, breast wounds in women patients with GLM have not been better managed. Therefore, the purpose of this study is to explore the disease experience of women patients with GLM, to provide a basis for the development of precise intervention and support strategies for women patients with GLM, and to further improve the quality of nursing management and enrich the research types of GLM.

Methods

In this study, 10 cases of GLM women patients from a tertiary hospital in Hangzhou, Zhejiang Province were selected by purposive sampling. After obtaining the informed consent of GLM women patients, semi-structured interviews were conducted with GLM women patients using the interview outline to collect qualitative data. The interview was recorded, transcribed verbatim in the local language, and then translated into English, and the content analysis method was used to analyze the data. The Consolidated Criteria for Reporting Qualitative Research (CORE-Q) checklist follows the report 's findings.

Results

Our study identified six themes: (a) Perception of the disease, (b) Emotional discomfort (c) Variety of changes (d) Lack of specific skills (e) Coping strategies adopted to rebuild health, (f) Expectation.

Conclusion

The experience of women with GLM is characterized by diversity and specificity. After experiencing physical trauma, most patients use support systems to change negative attitudes and rebuild physical and mental health. Family, hospital and society should be fully linked to strengthen the prevention of GLM and the popularization of nursing management knowledge; nurses should provide targeted nursing services. Nursing leaders should improve the medical security system, broaden the medical channels, and reduce the pain experience and pressure of patients.

Idiopathic Granulomatous Mastitis (IGM): Clinical Features and Non-Surgical Management

Background: Idiopathic Granulomatous Mastitis (IGM) is a benign disease; it can clinically and radiologically mimic the symptoms of breast cancer. Objectives: Due to the rare and limited number of studies in Iran, this study was designed and conducted to evaluate patients' clinical characteristics and treatment management with IGM. Methods: In this cross-sectional and retrospective descriptive-analytic study, we studied the medical records of 293 patients with IGM, such as demographic information, characteristics of breast lesions, type of treatment, complications, and their outcome, which were recorded in the Cancer Research Centers of Shahid Beheshti University of Medical Sciences (SBMU) from 2010 to 2019. The patients were contacted by telephone to visit clinically or collect additional information. Data were analyzed by SPSS software version 24. Results: The mean age of patients was 39.21 (ST = 8.29) years. Breast involvement in 236 cases (80.5%) was unilateral, and in 50 cases (17.1%), the involvement was Pere pri-Areola. The most common type of treatment was conservative therapy (analgesia + drainage) (178 cases, 60.8%), which was the primary treatment in our study; 66 patients (22.5%) received antibiotic therapy + analgesia + drainage, and 41(14%) cases received corticosteroid in addition to this treatment. Totally, 132 cases (79.5%) were completely cured with the performed treatments, 17 cases (5.8%) had a recurrence of symptoms, and 14.7% of the patients were still receiving treatment. Recurrence after 1 year in patients who had a longer duration of disease (more than 12 months) was higher than in those who had a shorter period (less than 12 months) (15.3% vs. 5.1%, P = 0.004). Also, the highest recurrence rate was in the group receiving corticosteroids compared to the group receiving the usual treatment and usual treatment plus antibiotics. This relationship was statistically significant (22.0% vs. 9 % and 6.1%, respectively, P = 0.032). Complications (scar or breast skin color change) were significantly higher in patients without a pregnancy history than in patients who had pregnancy (50.0% vs. 22.8%, P = 0.030). Also, these complications were significantly higher in patients who had a longer duration of disease (more than 12 months) than in shorter periods of disease (less than 12 months) (31.4% vs. 17.3%, P = 0.005). Conclusions: The results of our study and its comparison with the results of other studies still emphasize the uncertainty of the etiology of IGM disease and its treatment, but to some extent, our study has shown that conservative treatment (drainage with analgesic drugs) is one of the best treatment options. Also, corticosteroid therapy is associated with a higher recurrence rate, but in some cases is necessary and recommended in many studies.

Idiopathic granulomatous mastitis: introducing a diagnostic algorithm based on 5 years of follow-up of 152 cases from Turkey and a review of the literature

PURPOSE

The goals of this study were to report our clinical experience in a single center at a high-volume tertiary university hospital in Istanbul and to introduce a diagnostic algorithm based on a 5-year follow-up of 152 women with biopsy-proven idiopathic granulomatous mastitis (IGM). IGM is an uncommon, non-malignant, chronic inflammatory disease of the mammary gland with an unknown etiology. The symptoms, clinical presentation, and radiologic findings of IGM may resemble carcinomas. To our knowledge, this study comprises the largest series of IGM, especially with a 5-year follow-up, yet reported in the English literature.

METHODS

The present study reported our single-center clinical experience at a tertiary university hospital in Istanbul, Turkey, and introduced a diagnostic algorithm using our treatment protocol based on a 5-year follow-up of 152 women with biopsy-proven IGM. Our database of 10 years' experience containing over 700 patients with IGM was evaluated. However, to assess recurrence and resistance to treatment, only the 152 patients with a long follow-up period of 5 years were included in the study group. The analysis included 152 women with biopsy-proven IGM who were treated between January 2009 and March 2014. The clinical data of the presentation, histopathology, and treatment modalities were analyzed by reviewing the medical records.

RESULTS

Of the 152 patients diagnosed with granulomatous mastitis, 32 (21%) recovered by expectant management, while 14 (9%) responded to antibiotics, 65 (43%) received corticosteroids, 20 (13%) had antituberculosis medication, 16 (11%) underwent excision, and 5 (3%) responded to non-steroidal anti-inflammatory drugs. Fifty-one patients (33%) had recurrence; of these, 30 achieved a cure with second-line treatment, 16 underwent excision, and 5 achieved a cure with observation.

CONCLUSION

IGM is a rare benign breast disorder, and clinicians need a high index of suspicion to diagnose it, as IGM can be mistaken for breast cancer. Unlike periductal mastitis, IGM does not evolve secondary to nicotine addiction and is typically seen in women of childbearing age with a recent history of pregnancy and lactation. The diagnosis can be challenging, and an evaluation with a multidisciplinary team is necessary. There is no consensus concerning the definitive treatment approach. We suggested a diagnostic algorithm in the present study, using our treatment protocol based on the 5 years' follow-up of 152 women.

Treatment of idiopathic granulomatous mastitis using ultrasound-guided microwave ablation: a report of 50 cases

OBJECTIVE

This study aimed to evaluate the efficacy and safety of ultrasound-guided microwave ablation combined with glucocorticoid therapy for treating idiopathic granulomatous mastitis (IGM).

METHODS

From June 2017 to March 2020, 50 consecutive patients diagnosed with IGM using puncture histology were included. All patients received prednisone and ultrasound-guided microwave ablation and were closely monitored for 12-15 months.

RESULTS

A total of 222 lesions in 50 patients were ablated. The results indicated that 78% of cases were cured within 12 months and an additional 20% were cured within 15 months; the recurrence rate was 2%. The clinical and pathological remission rate of the entire group was 98%. The main postoperative complications were local pain, skin ulcerations and sinus formation, skin and areola heat damage, subcutaneous congestion, and fat liquefaction, all of which were conservatively treated.

CONCLUSION

Microwave ablation combined with glucocorticoid therapy was safe and effective for the treatment of IGM, with a low recurrence rate. In addition, the cosmetic appearance of the affected breast was preserved with little trauma. Therefore, microwave ablation is a viable method that can be successfully applied in clinical practice.

Idiopathic granulomatose mastitis. Case report and literary review

The clinical case of a patient with a histological diagnosis of idiopathic granulomatous mastitis is described, a rare disease in which immunosuppressants are used as the described treatment and can be confused with other entities treated in the specialty. The case is described and a literature review is carried out.

The effect of methotrexate monotherapy on treatment-resistant idiopathic granulomatous mastitis patients

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is a disease of unknown etiology, involving a chronic inflammatory process, characterized by noncaseating granuloma formation. IGM can mimic a tumor clinically and radiologically. Since we are a tertiary referral center, most of our patients (n = 56, 87.5%) are secondary admissions who have previously had antibiotics and steroid treatments; therefore, we accept these patients as resistant cases. Here, we aim to present our single-center series of 64 patients with resistant IGM who underwent methotrexate monotherapy. To the best of our knowledge, our study includes the highest number of patients described in the literature with IGM who have undergone this treatment.

METHODS

This study included 64 patients, 56 of which were resistant cases, diagnosed with IGM between January 2013 and January 2020 at Istanbul University Cerrahpasa, Cerrahpasa Medical Faculty, General Surgery Breast Outpatient Clinic that were followed-up at least once. These patients were administered oral methotrexate monotherapy 15 mg/week for 24 weeks, and in relapsed cases, the treatment was up to 20 mg/week for 1 year. Folic acid 10 mg/week was given as a supplement to all patients.

RESULTS

Complete recovery was observed in 52 (81.25%) of the 64 patients. Follow-up was discontinued by 4 patients. The dose was increased and the duration of treatment was extended up to 1 year when relapse was observed in 8 patients and complete response was then obtained in these cases. Only 3 patients (4.69%) experienced side effects and were switched to subcutaneous treatment due to nausea.

CONCLUSION

Considering the high patient compliance, low recurrence, minimal side effects, and overall success of the treatment, we believe that methotrexate monotherapy may be used in treatment-resistant IGM patients and may also be the first choice for first-line treatment in the future.

Management of idiopathic granulomatous mastitis in lactation: case report and review of the literature

Background

Idiopathic Granulomatous Mastitis (IGM) is a benign chronic inflammatory breast condition that mimics two common breast disorders: breast carcinoma and breast abscess. It can form breast masses, fistulae, and fluid collections, resulting in breast disfigurement with retraction and nipple areolar complex (NAC) inversion. IGM most often presents in women of childbearing age within a few years of pregnancy, and can significantly impact lactation. Despite the prevalence of this disease, no current literature describes an approach to managing IGM during breastfeeding.

Case presentation

A 28-year-old G3P2 patient of Native American origin presented to her obstetrician at 7 months pregnant with worsening left breast swelling and redness. She underwent a mammogram, ultrasound and core needle biopsy that confirmed the diagnosis of Idiopathic Granulomatous Mastitis. During the postpartum period, she underwent intralesional triamcinolone injections of her left breast. Due to the contraindication of breastfeeding after local steroid injection, the patient stopped breastfeeding from the affected breast and continued breastfeeding unilaterally.

Conclusions

Idiopathic Granulomatous Mastitis is a challenging chronic inflammatory breast disease that affects women primarily in the reproductive years, with a higher incidence in patients of Hispanic, Native American, Middle Eastern, and African descent. Treatment of IGM during pregnancy and lactation has thus far not been addressed. We review the literature on the treatment of IGM in the non-lactating population, and propose considerations for treating breastfeeding women affected by this disease. Traditional treatment has included systemic immunosuppression and surgery, but newer literature demonstrates that intralesional injection of steroid can provide significant symptomatic relief to patients. A diagnosis of IGM does not preclude breastfeeding, though patients may experience challenges with milk production and latch on the affected breast. Individualized care should be provided, with considerations given to the following: side effects of systemic steroids, the need to wean a breast being treated with intralesional steroids, and augmentation of milk production on the unaffected breast to promote continued breastfeeding.

Treatment of idiopathic granulomatous mastitis and factors related with disease recurrence

Background/aim

Idiopathic granulomatous mastitis is a rare, benign inflammatory disease of breast. There is no general agreement on the appropriate treatment choice. The aim of the study was to investigate the immunosuppressive administer for idiopathic granulomatous mastitis and risk factors related with disease recurrence.

Materials and methods

The data of 53 patients with idiopathic granulomatous mastitis were evaluated for this cross-sectional retrospective study. Demographic features and clinical characteristics and course of the patients were obtained from file records.

Results

The mean age of the patients was 37.2 ± 6.6 years. Fifty-one of 53 patients received immunosuppressive treatment with or without surgery. Forty-seven (88.6%) of the patients received only immunosuppressive treatment without surgery, while 4 (7.54%) patients received immunosuppressive treatment after surgery. Forty-one (77.3%) of 47 patients who had no surgical resection received methotrexate as immunosuppressive treatment. The other 6 (11.3%) patients received azathioprine or corticosteroid treatment. Complete or partial remission was observed in 50 (98%) of 51 patients who received immunosuppressive treatment, while only 1 (2%) patient did not reach remission. No factors were found related with recurrence of disease.

Conclusion

Methotrexate seems to be efficient in the treatment of idiopathic granulomatous mastitis and provides drug-free remission.

A Novel First-Line Treatment Alternative for Noncomplicated Idiopathic Granulomatous Mastitis: Combined İntralesional Steroid İnjection with Topical Steroid Administration

Background

Idiopathic granulomatous mastitis (IGM) is a rare form of nonlactational mastitis. Due to the small number of case series and consequently inadequate prospective studies, there is still no consensus on the optimal treatment of IGM. In this study, we aimed to compare the efficacy of intralesional steroid injection with concomitant topical steroids to systemic steroid therapy only in the treatment of noncomplicated IGM.

Methods

Between June 2015 and April 2018, the patients' data was prospectively collected and analyzed retrospectively. The study included a total of 78 female patients diagnosed with IGM. Patients were divided into 2 groups: the local steroid treatment group (intralesional steroid injection with topical steroid administration; group 1, n = 46) and the peroral systemic steroid treatment group (group 2, n = 32). Response to the therapy, side effects, recurrence, the need for surgical treatment, and complication rates were compared.

Results

Forty-three patients (93.5%) in group 1 achieved a partial or complete response compared to 23 patients (71.9%) in group 2 after 3 months; this difference was significant (p = 0.012). The recurrence rates were significantly lower in group 1 (8.7%) compared to group 2 (46.9%; p = 0.001), and the need for surgical treatment was significantly less in group 1 (2.2%) than in group 2 (9.4%; p = 0.001). While the complication rates were similar between groups, a higher rate of systemic side effects was observed in group 2.

Conclusion

Based on the results of our study, combined steroid injection and topical steroid treatment in IGM is as effective as systemic steroid treatment. We suggest that this combination therapy of topical steroids and local steroid injection should be used as first-line therapy in patients with noncomplicated IGM.

Comparison of Conservative versus Surgical Treatment Protocols in Treating Idiopathic Granulomatous Mastitis: A Meta-Analysis

Background

Idiopathic granulomatous mastitis (IGM) is a rare, benign breast disease without any definitive therapeutic strategy. It is controversial whether to use conservative or surgical treatment of IGM and high-level evidence-based medicine data are lacking. The purpose of this study was to systemically evaluate the clinical effectiveness of the conservative versus surgical treatment for IGM.

Methods

In this meta-analysis, we searched PubMed, EMbase, ScienceDirect, and Web of Science for comparative studies about the conservative versus surgical treatment of IGM. Two researchers independently identified reports and extracted data. We used Stata 11 for data analysis. A meta-analysis was performed to investigate the differences in the recurrence rate of conservative and surgical treatment using a random effects model.

Results

A total of 10 studies involving 1,101 patients were included. The results demonstrated that there was no significant difference in the recurrence rate among patients who were treated by nonsurgical therapy and surgical treatment. No publication bias was detected.

Conclusion

This meta-analysis demonstrates that both the conservative and surgical treatment approaches have appropriate efficacy in IGM treatment and relapse. Further randomized controlled trials with longer follow-up periods are required to confirm the advantages of each approach.

Idiopathic Granulomatous Mastitis: Manifestations at Multimodality Imaging and Pitfalls

Idiopathic granulomatous mastitis (IGM) is a rare benign inflammatory breast entity characterized by lobulocentric granulomas. IGM has a persistent or recurrent disease course and affects parous premenopausal women with a history of lactation. It has also been associated with hyperprolactinemia. The most common clinical sign is a palpable tender mass. However, the nonspecific manifestations and varied demographic features of this condition, as well as the other similar-appearing and superimposed breast entities, pose substantial diagnostic challenges. Entities with similar manifestations include inflammatory breast cancer (IBC), infective mastitis, foreign body injection granulomas, mammary duct ectasia, diabetic fibrous mastopathy, and systemic granulomatous processes. The strategy for imaging IGM depends on patient age, clinical manifestations, and risk factors. Targeted ultrasonography, mammography, and less commonly, magnetic resonance imaging have proven to be useful for imaging evaluation. Core-needle biopsy, with or without fine-needle aspiration for cytopathologic examination, and culture analysis are usually required to exclude IBC and other benign inflammatory breast processes. Patients with IGM have an excellent prognosis when they are appropriately treated with oral steroids or second-line immunosuppressive and prolactin-lowering medications. However, surgical excision may be an option for patients in whom medication therapy is unsuccessful. Imaging surveillance can be offered to patients with incidentally encountered IGM or mild symptoms. Clinical suspicion for this rare disease and the breast imager's prompt diagnosis can lead to an improved patient outcome. The purpose of this article is to review the imaging manifestations of IGM in a multimodality case-based format and to describe relevant clinical and imaging-based differential diagnoses. The associated pitfalls, epidemiologic and histopathologic factors, clinical manifestations, natural course, and management of IGM also are discussed. ©RSNA, 2018.

Idiopathic Granulomatous Mastitis: A Clinical Puzzle in Breast Lump Cases

Idiopathic granulomatous mastitis (IGM) is a rare benign disease, characterized by chronic inflammation and granulomatous disease process. A middle aged lady with breast lump for six months with equivocal mammographic and ultrasound results underwent lumpectomy and biopsy. Ruling out all other possible granulomatous diseases and malignancy, a diagnosis of IGM was made. IGM becomes clinically significant as it closely mimics carcinoma breast and some inflammatory and infectious pathology.

Rifampicin for Idiopathic Granulomatous Lobular Mastitis: A Promising Alternative for Treatment

BACKGROUND

Idiopathic granulomatous lobular mastitis (IGLM) is a chronic, non-caseating, inflammatory breast disease of obscure aetiology characterized by multiple masses, abscesses and sinus formation. There is no standard treatment to date, but surgical procedures and systemic corticosteroids are effective in its treatment despite high recurrence rates.

PATIENTS AND METHODS

This prospective study including 30 patients with IGLM between November 2012 and May 2016 aimed to investigate the possibility of administration of Rifampicin (300 mg twice daily for a period of 6-9 months) as an alternative therapy for both surgery and corticosteroids in patients with IGLM. All patients were diagnosed by core needle biopsy.

RESULTS

All patients were of reproductive age and had a history of breast feeding, which is the most important predisposing factor for IGLM. The mean age was 31.6 ± 5.8 years (range 23-42 years). Eighteen patients (60%) were treated by Rifampicin for 6 months, whereas 12 patients (40%) were treated for 9 months. Twelve months after the beginning of therapy, all patients showed complete clinical and ultrasonographic responses. No serious side effects were reported to stop the treatment course. The median follow-up after finishing the course of treatment was 15.5 months (average 3-35 months) with no episodes of disease relapse.

CONCLUSION

Rifampicin is effective in the treatment of patients with IGLM with complete clinical and ultrasonographic response after 6-9 months and could be used as a solo medical therapy alternative to both surgery and corticosteroids.

Steroids administered after vacuum-assisted biopsy in the management of idiopathic granulomatous mastitis

AIMS

The aetiology and treatment options for idiopathic granulomatous mastitis (IGM) are controversial. The aim was to study the clinical and diagnostic features and discuss medical and surgical treatment for IGM in our patients.

METHODS

Sixty-five patients who met the histological criteria for IGM were retrospectively studied. The diagnosis of IGM was confirmed using Mammotome (an ultrasound-guided, vacuum-assisted biopsy system), core needle biopsy, quadrantectomy or segmental resection. Forty-five patients were treated with prednisolone (69.2%). Immunohistochemical (IHC) staining for immune-related antigens (CD3, CD4, CD8, CD79a, IgG, and IgM) was performed.

RESULTS

Ultrasonography (USG) was carried out in all patients. Among them, 61 were considered to have an inflammatory mass and 15 had accompanying liquefaction. In four patients, the findings mimicked breast carcinoma (6.2%). The IHC results showed CD3, CD4, CD8 and CD79a lymphocytes diffusely distributed in the lesion. Stains for IgG and IgM were negative. Prednisolone was administered to the patients diagnosed with IGM. The success rate was 53 (81.5%) and the whole recurrence was 12 (18.5%). The median follow-up period was 12 months (range 4-42 months).

CONCLUSIONS

The aetiology of IGM remains uncertain. The disease has no propensity for the right or left breast. It is a local autoimmune disease, involving humoral and cell-mediated immunity. Hyperprolactinaemia may play a role in some patients. Corticosteroids administered after complete removal of the IGM lesion using the Mammotome biopsy system is an effective treatment option.

Chronic Mastitis in Egypt and Morocco: Differentiating between Idiopathic Granulomatous Mastitis and IgG4-Related Disease

Idiopathic granulomatous mastitis (IGM) is a benign, frequently severe chronic inflammatory lesion of the breast. Its etiology remains unknown and reported cases vary in their presentation and histologic findings with an optimal treatment algorithm yet to be described owing mainly to the disease's heterogeneity. IgG4‐related disease (IgG4‐RD) is a newly recognized systemic fibroinflammatory condition characterized by a dense lymphoplasmacytic infiltrate with many IgG4‐positive plasma cells, storiform fibrosis, and obliterative phlebitis. Immunosuppressive therapy is considered to be an effective first‐line therapy for IgG4‐RD. We sought to clarify and classify chronic mastitis according to the histologic findings of IgG4‐RD mastitis with respect to IGM and to develop a robust diagnostic framework to help select patients for optimal treatment strategies. Using the largest collection to date (43 cases from Egypt and Morocco), we show that despite sharing many features, IGM and IgG4‐RD mastitis are separate diseases. To diagnostically separate the diseases, we created a classification schema—termed the Michigan Classification—based upon our large series of cases, the consensus statement on IgG4‐RD, and the histologic description of IGM in the literature. Using our classification, we discerned 17 cases of IgG4‐RD and 8 cases of IGM among the 43 chronic mastitis cases, with 18 indeterminate cases. Thus, our Michigan Classification can form the basis of rational stratification of chronic mastitis patients between these two clinically and histopathologically heterogeneous diseases.

Idiopathic granulomatous mastitis: presentation, investigation and management

Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory condition of the breast which although benign can mimic carcinoma. Establishing a diagnosis can be challenging and requires a high index of suspicion with exclusion of infective and autoimmune breast diseases. IGM is characterized histologically by noncaseating granulomas which are of a lobulo-centric pattern and often associated with microabscess formation. Management of confirmed cases remains controversial with proponents of initial surgical or medical therapies - each has its associated problems which can be worse than the original symptoms of IGM. However, many patients require more than one modality of treatment to completely resolve IGM lesions and careful judgment is necessary to ensure optimal type and sequencing of treatments.

Association between Hyperprolactinemia and Granulomatous Mastitis

Granulomatous mastitis (GM) is a relatively uncommon inflammatory breast lesion with multiple suggested etiologies. Although most GM cases show association with lactation and pregnancy, a minority of cases have been linked to hyperprolactinemia caused by either dopamine antagonist medications or with intracranial lesions, such as pituitary adenoma. The goal of this study is to review the GM cases reported in the literature with a specific emphasis on those cases associated with hyperprolactinemia and prolactinomas and to identify cases of GM seen at the Cleveland Clinic Florida which demonstrate co-occurrences of GM and intracranial lesions. CoPath and Epic data bases at Cleveland Clinic Florida were searched for cases describing inflammatory breast lesions in patients with pituitary pathology. Chart reviews were conducted and pertinent medical history was extracted for case reports. H&E-stained paraffin-embedded sections retrieved from Cleveland Clinic Florida pathology storage were evaluated by light microscopy. Four cases showing a co-occurrence of GM and hyperprolactinemia were consequently identified. A prolactin-secreting pituitary adenoma was present in two of the three GM cases. The third case demonstrated a concomitant craniopharyngioma, which was also associated with a rise in serum prolactin. This phenomenon was presumably attributable to compression, resulting in compromised transport of dopamine to the adenohypophysis and subsequent disinhibition of prolactin secretion by lactotrophs. The fourth patient with GM had a similar history of elevated prolactin. Classical histopathological features of GM were found in all four cases, including noncaseating granulomas, multinucleated giant cells, epithelioid histiocytes, and chronic inflammation. Intriguingly, complete resolution of inflammatory breast lesions along with normalization of prolactin levels occurred following the surgical excision of the craniopharyngioma, suggesting that intracranial lesion-induced hyperprolactinemia might be directly causal in GM. Therefore, the authors would suggest screening for pituitary tumors and evaluate prolactin levels in the workup of GM patients without a recent history of lactation and pregnancy and no other identified etiology.

Bilateral idiopathic granulomatous mastitis

OBJECTIVES

Idiopathic granulomatous mastitis (IGM) is a benign rare inflammatory pseudotumor. Bilateral involvement of IGM has been reported in a few cases. To our knowledge, this study is the largest series of bilateral cases to date. The goals of this study were to present clinical features of bilateral IGM and to evaluate the results of treatments.

MATERIALS AND METHODS

We performed a retrospective review of the idiopathic granulomatous mastitis database from 2010 to 2013. Ten female patients who met required histologic and clinical criteria of IGM in both breasts were included in study. Demographic data, clinical findings, medication history, and radiologic findings are presented.

RESULTS

The mean age at onset of the disease was 38.4 ± 8.3 years (range: 29-52 years). Nine patients had no recurrence during a mean follow-up period of 21 months (range: 11-26 months). Additionally, the median time to second breast involvement was 15.6 months.

CONCLUSION

Bilateral IGMs have a higher rate of more relapse and greater resistance to medical therapies than do unilateral IGMs. Surgical management should be avoided unless all medical treatment options have been exhausted. Nevertheless, expectant management seems a rational option for the treatment of bilateral IGM.

A Comparative Study of Conservative versus Surgical Treatment Protocols for 77 Patients with Idiopathic Granulomatous Mastitis

The purpose of this study was to analyze the clinical features and demographic data of patients with idiopathic granulomatous mastitis (IGM) and to compare the results of conservative versus surgical treatment protocols. The demographic data, clinical findings, microbiological and pathologic features, scanning and treatment methods, recurrence, and recovery rates of 77 patients were analyzed retrospectively. The patients were divided into two groups based on the type of treatment received. Core biopsies were used to diagnose 37 patients: 26 using incisional biopsies and 14 using excisional biopsies. Of the patient population with IGM, 31 were treated with surgical excision, one with a simple mastectomy, and one with a subcutaneous mastectomy combined with a breast implant, whereas 44 were treated with steroids. The recovery rates of the 44 patients who were treated conservatively were 6 (1-15) months while for the 33 patients who were treated surgically, it was 1 (1-5) month (p = 0.001). Nine patients from the conservative treatment group experienced a recurrence while there were no recurrences in the surgically treated group (p = 0.009). Among all patients, the recurrence rate was 11.7% (9/77) while the average follow-up period was 16.57 ± 18.57 months. As a comparative study between conservative treatment protocols and surgical ones for patients with idiopathic granulomatous mastitis (IGM), this study is the largest to date. A wide surgical excision is the preferred approach for treating patients with IGM because of the low recurrence rate.

Can Steroids plus Surgery Become a First-Line Treatment of Idiopathic Granulomatous Mastitis?

BACKGROUND

The aim of this study is to compare the clinical course of idiopathic granulomatous mastitis (IGM) treated with low-dose oral corticosteroid therapy alone as opposed to treatment with low-dose corticosteroid therapy followed by surgery.

PATIENTS AND METHODS

37 patients were treated with an approach that consisted of methylprednisolone at a dose of 0.5 mg/kg/day followed by wide excision, and 23 patients were treated with an approach that consisted only of methylprednisolone. The treatment efficacy was compared between the two groups.

RESULTS

Clinical and radiological regression was reported in all patients with steroid therapy, and the regression rate had a median of 75% (25-100%). No recurrence was observed in patients who were treated with wide surgical excision after steroid therapy during the median follow-up period of 38 (22-78) months. The control group of 23 patients was treated only with steroid therapy, and 7 (30%) of these patients experienced recurrence in the follow-up period (p < 0.001).

CONCLUSIONS

Steroid therapy was effective in the treatment of IGM by reducing the lesion size and extent. With regard to the current treatment options available for IGM, surgical excision after steroid therapy seems the better treatment option compared to steroid therapy without surgical excision. This treatment sequence reduces the rate of recurrence.

Corticosteroid treatment in the management of idiopathic granulomatous mastitis to avoid unnecessary surgery

PURPOSE

Idiopathic granulomatous mastitis (IGM) is a rare benign inflammatory disease of the breast. It can mimic breast carcinoma clinically and radiologically, and usually affects females of childbearing age. There is no commonly accepted optimal treatment for IGM. In this study, we present the clinical and histopathological features and outcomes of the therapeutic management of IGM, as well as the clinical course of the disease when patients were treated with oral corticosteroids.

METHODS

This retrospective study included 49 of 87 patients who met the required histological criteria for IGM who were followed up between January 2009 and December 2011. All patients had a disease-free follow-up period of at least 6 months. The data regarding the clinical features at presentation, laboratory values and the treatment modalities were obtained from the medical records of the patients.

RESULTS

The mean age of the patients was 34.3 ± 4.37 years. Forty patients were treated with prednisolone, five were started on antituberculosis treatment, two received non-steroidal anti-inflammatory drugs, one received antibiotics and one underwent wide excision. All patients who received steroids responded well to the therapy.

CONCLUSION

Systemic therapy with corticosteroids is an effective and appropriate treatment option for IGM. It can provide complete disease resolution and prevent recurrence in the long term. A multidisciplinary approach including specialists in the fields of both general surgery and infectious diseases is essential for the diagnosis, treatment and follow-up of IGM.

Management of idiopathic granulomatous mastitis diagnosed by core biopsy: a retrospective multicenter study

Idiopathic granulomatous mastitis (IGM) is a rare, benign, chronic inflammatory condition of the breast, which usually mimics breast carcinoma. The aim of this study was to analyze the clinical features of IGM by identifying a more reliable diagnostic protocol, and evaluating the treatment methods and patient outcomes on follow-up. We performed a retrospective analysis of 46 patients diagnosed with IGM and managed by the same surgical team between 1999 and 2011, at three high-volume hospitals. The median age of the patients was 33 years. The most common symptom was painful breast mass (n = 39), followed by abscess (n = 11). All patients underwent ultrasonography (USG). Mammography (MG) and magnetic resonance imaging (MRI) were also performed in 20 patients (43%) and 17 patients (37%), respectively. The mean size of the lesions was 32.8 ± 8.8 mm and ranged from 15 to 50 mm. Preoperative diagnosis of IGM was established by core needle biopsy (CNB) under USG guidance. Eighteen patients (39%) underwent complete excision of the lesion and 25 (54%) were treated with steroids. Three patients treated with steroids subsequently underwent local excision. The mean follow-up period was 35.4 ± 30.9 months. Eight patients (17%) developed disease recurrence; three of these were successfully treated with steroids, one with surgery, and four with both steroids and surgery. CNB in conjunction with high diagnostic accuracy has a significant role in distinctive diagnosis of IGM and hence, is useful for treatment planning. Treatment can be designated according to the extent and the severity of the disease, and the patient's general health and treatment preferences. Patients with IGM must be closely followed up due to the frequency of disease recurrence.

Chronic granulomatous mastitis: Imaging, pathology and management

PURPOSE

The aim of this study is to describe the clinical and radiological presentation of chronic granulomatous mastitis.

MATERIAL AND METHODS

We retrospectively reviewed the clinical and radiological data of 11 women with histologically proven chronic granulomatous mastitis (CGM) diagnosed between March 2008 and September 2011.

RESULTS

The diagnosis of CGM is often a challenging one that can mimic infectious and malignant breast conditions. Clinically, CGM most commonly presents as a mass, occasionally with associated erythema. The most frequent mammographic presentation is an asymmetric density, while ultrasound most commonly reveals a hypoechoic mass with tubular extensions and a striated echotexture. On MRI, the most specific finding is peripherally enhancing fluid or solid masses with fistulous tract to the skin, although the latter is not commonly encountered. Diagnosis can be reliably obtained by needle core or vacuum-assisted biopsy, and is established pathologically by the identification of granulomatous inflammation without caseous necrosis. CGM is a diagnosis of exclusion after infectious and foreign body causes are ruled out. Treatment options include oral steroids or surgery; both options are associated with similar recurrence rates. The disease tends to burn itself out and the option of conservative management with observation is a valid one.

CONCLUSION

CGM is a rare benign disease with no specific features clinically or at imaging. There are no radiologic findings that are specific of CGM, but in the appropriate clinical setting, the diagnosis can be suggested by the radiologist.

Methotrexate in the management of idiopathic granulomatous mastitis: review of 108 published cases and report of four cases

This study aimed to discuss the role of agents, such as steroids and methotrexate (MTX), in the treatment of patients with idiopathic granulomatous mastitis (IGM). Using Pubmed and Google Scholar data bases, a retrospective study was carried out on IGM cases treated with steroids and/or MTX between 1972 and 2010. Four IGM cases treated with MTX at our clinic were also summarized in this study. A total of 541 IGM cases since 1972, including ours, were retrospectively analyzed. Steroid treatment 5-85 mg was administered over 5 days-22 months to 112 patients aged 21-48 years. Recurrence occurred in 22 patients, steroid-induced diabetes mellitus in 5 patients, no response to treatment was observed in 4 patients, in 2 patients, the mass decreased in size, and static disease was observed in one. The steroid treatment was changed to MTX treatment in 4 patients who had recurrence, 5 with steroid-induced DM and in 4 who were nonrespondents. Three patients were started on steroid together with MTX as a primary treatment. Of the patients treated with MTX, a satisfactory result was obtained in 14 cases and in 2, mastectomy was performed because of recurrence despite the treatment with MTX. IGM is a troublesome condition that presents management problems due to the side effects of steroids. Our study demonstrates that the use of MTX in IGM cases has been effective in preventing complications, in resolving the inflammatory process, and in limiting side effects of corticosteroids.

Is methotrexate an acceptable treatment in the management of idiopathic granulomatous mastitis?

PURPOSE

The treatment of choice for idiopathic granulomatous mastitis (IGM) has not yet been established. There are limited data on the use of methotrexate (MTX) in the treatment of IGM. Herein, we investigated the role of MTX in the treatment of IGM patients.

METHODS

We present four new cases of IGM treated with MTX and a review of the English language literature concerning the use of MTX in the treatment of IGM.

RESULTS

We prospectively investigated the clinicopathological features of four female patients (aged 28-37 years) who were multiparous and had used oral contraceptives. The patients were administered 7.5-15 mg MTX over 2-6 months. No recurrence was detected during the follow-up period of 4-8 months. In five published studies on MTX use in IGM, data were available for 12 patients aged 21-40 years. In nine patients, treatment was changed to MTX because of a lack of response to steroids, recurrence or steroid-induced diabetes mellitus. Steroids were used in combination with MTX as an initial treatment choice in three patients. Satisfactory results were achieved in ten patients treated with MTX, and only two demonstrated recurrence despite the treatment and underwent mastectomy.

CONCLUSION

MTX in the present cases of IGM was effective, prevented complications and limited corticosteroid side effects.

Idiopathic granulomatous mastitis: a great imitator?

The patient in this case was seen by numerous doctors for a long time before the diagnosis was made because, right from the start, an abscess or a cancer of the breast was suspected. She was first seen by her general practitioner (GP); thereafter, she went to two consultant physicians and a surgeon in a regional hospital and eventually an idiopathic granulomatous mastitis (IGM) diagnosis was made by a specialist in internal medicine in a university hospital. When the diagnosis IGM was made, the patient was treated with steroids and made a complete recovery. Although the incidence of IGM is not high, the GPs are likely to see these patients initially and should be aware of the existence of this disease, which may spare the patient unnecessary consultations, diagnostics tests or even mastectomy.