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

>Efficacy of disease-modifying antirheumatic drugs in the treatment of granulomatous mastitis: a systematic review

INTRODUCTION

Idiopathic granulomatous mastitis (IGM) is an inflammatory breast disorder of unknown etiology. This benign condition can mimic the clinical presentation of breast cancer and is characterized by symptoms such as breast pain, erythema, and swelling. Over the past few years, Disease-Modifying Antirheumatic Drugs (DMARDs) have been increasingly used to manage this condition. However, strong evidence to support their use is lacking.

OBJECTIVES

This systematic review aimed to summarize the evidence and evaluate the efficacy of DMARDs in the management of IGM.

METHODS

A systematic literature review, adhering to PRISMA guidelines, was conducted across electronic databases, including PubMed, EMBASE, SCOPUS, directory of open access journals (DOAJ) and Cochrane Library from their inception until May 2024. We included retrospective and prospective studies while excluding case reports and case series of less than 10 patients.

RESULTS

Eighteen studies met our eligibility criteria. Fifteen studies were retrospective, while 2 were prospective. No randomized controlled trials were identified. Of these, 16 papers examined the effect of methotrexate on IGM, revealing significant disease improvement in most cases. Several of the studies indicated that patients treated with azathioprine and mycophenolate mofetil also achieved favorable responses.

CONCLUSION

Given the rarity of IGM, only a limited number of studies have explored the use of DMARDs as a pharmacological treatment option. A significant barrier to advancing our understanding is the substantial heterogeneity in the quality and volume of data provided by these studies. Therefore, there is a need for well-designed, randomized, placebo-controlled trials to rigorously assess the efficacy of DMARDs in the treatment of IGM.

Current approaches to diagnosing and treating idiopathic granulomatous mastitis: A summary from in-depth clinician interviews

Background

Idiopathic granulomatous mastitis (IGM) is a rare, chronic inflammatory breast condition primarily affecting women of reproductive age. Its diagnosis is challenging due to similarities with other breast disorders, necessitating exclusion of other granulomatous diseases. The management of IGM remains inconsistent and unclear, with high recurrence rates and varying practices.

Methods

This qualitative study involved semi-structured interviews with nine clinicians from Singapore, Malaysia, and Egypt to examine current diagnostic and therapeutic approaches for IGM. Transcripts were analysed using NVivo software for coding and summarisation.

Findings

Clinicians predominantly used imaging and histopathology for diagnosis. Treatment commonly involved corticosteroids, though dosages and tapering regimens varied widely. Methotrexate was used sparingly for refractory cases due to associated risks. Surgical interventions were infrequent, reflecting a preference for medical management. There was a consensus on the need for randomised controlled trials (RCTs) to establish standardised treatment protocols.

Interpretation

This study reveals the complex nature of IGM diagnosis and treatment from clinicians in Singapore, Malaysia and Egypt. This underscores the need for more specific and definitive diagnostic tests, rather than relying on exclusionary methods, and standardised treatment guidelines. Multi-centre RCTs are essential for developing evidence-based protocols to improve patient outcomes and address regional differences effectively.

Refractory and Recurrent Idiopathic Granulomatous Mastitis Treatment: Adaptive, Randomized Clinical Trial

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is mostly described as an autoimmune disease with higher prevalence among Middle Eastern childbearing-age women. This study aimed to evaluate the best treatment of choice in patients with resistant or recurrent IGM.

STUDY DESIGN

Patients with established recurrent or resistant IGM who were referred to the Breast Cancer Research Center from 2017 to 2020 were randomly assigned to either one of the following treatment groups: A (best supportive care), B (corticosteroids: prednisolone), and C (methotrexate and low-dose corticosteroids). This adaptive clinical trial evaluated radiological and clinical responses, as well as the potential side effects, on a regular basis in each group, with patients followed up for a minimum of 2 years.

RESULTS

A total of 318 participants, with a mean age of 33.52 ± 6.77 years, were divided into groups A (10 patients), B (78 patients), and C (230 patients). In group A, no therapeutic response was observed; group B exhibited a mixed response, with 14.1% experiencing complete or partial responses, 7.7% maintaining stability, and 78.2% experiencing disease progression. Accordingly, groups A and B were terminated due to inadequate response. In group C, 94.3% achieved complete response, 3% showed partial remission, and 2.7% had no response to therapy. Among the entire patient cohort, 11.6% tested positive for antinuclear antibodies, 3.5% for angiotensin-converting enzyme, and 12.3% for erythema nodosum. Notably, hypothyroidism was a prevalent condition among the patients, affecting 7.2% of the cohort. The incidence of common side effects was consistent across all groups.

CONCLUSIONS

The most effective treatment option for patients with recurrent or resistant IGM is a combination therapy involving steroids and disease-modifying antirheumatic drugs such as methotrexate.

Imiquimod as a new treatment in refractory idiopathic granulomatous mastitis: report of two cases

INTRODUCTION

Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory lesion of the breast that mimics breast cancer or infection. Immunological pathogenesis is strongly suggested for the disease.

REASON FOR THE REPORT

The treatment remains controversial, comprising a spectrum from observation or NSAIDs to immunosuppressive agents and surgery. Intractable cases are not uncommon and represent a major treatment challenge. Therefore in this study, we examine the effect of a topical immunomodulator agent, imiquimod, on refractory IGM. Patient 1 had IGM for 9 months and had not responded to the existing treatments. She responded to a 7-week course of imiquimod. In patient 2, the disease had begun 4 months sooner and had been resistant to all treatments; it responded to imiquimod after 4 weeks. Ulcers appeared on the skin of both patients but resolved safely.

OUTCOME

Both patients were very satisfied with the results. Imiquimod can be an appropriate local treatment with limited adverse effects in refractory IGM. We propose similar studies to assess the efficacy of imiquimod in IGM further, paying attention to the possibility of developing skin wounds.

A meta-analysis of idiopathic granulomatous mastitis treatments for remission and recurrence prevention

Purpose

The major aim of our meta-analysis was to review the effectiveness of various treatment modalities for achieving successful remission and preventing recurrence for women with idiopathic granulomatous mastitis (IGM). This knowledge is instrumental in developing evidence-based guidelines for clinicians to improve management strategies and outcomes for patients with IGM.

Methods

A systematic literature search was performed on MEDLINE (Ovid), Embase (Elsevier), PubMed, Cochrane Library, Web of Science, and Google Scholar; studies published to 19 January 2022 were included. A meta-analysis of 57 observational studies was performed. The results of two randomized controlled trials were also examined.

Results

There were 3,035 IGM patients across the observational and randomised studies. Overall recurrence and remission rates across all treatment strategies in 59 studies are 87.9% (2,667/3035) and 13.5% (359/2667), respectively. The studies reported 19 different treatment strategies, comprising observation, medical monotherapies, surgery, and combinations involving medical therapies, with and without surgery. Among monotherapy treatment, surgical management had the highest pooled remission rate (0.99 [95% confidence interval (CI) = 0.97-1.00]); among combination therapy, this was steroids and surgery (0.99 [0.94-1.00]). Antibiotic monotherapy had the lowest remission rate (0.72 [0.37-0.96]). The highest recurrence rates belonged to treatments that combined antibiotics and surgery (0.54 [0.02-1.00]), and antibiotics, steroids, and surgery (0.57 [0.00-1.00]). Most successful for preventing recurrence were observation (0.03 [0.00-0.10]), methotrexate (0.08 [0.00-0.24]), and steroids and surgery (0.05 [0.01-0.12]). There is a significant association between longer follow-up duration and recurrence rate reported, p = 0.002.

Conclusion

Combination therapies, especially those incorporating antibiotics, steroids, and surgery, have demonstrated higher remission rates, challenging the use of antibiotic monotherapy. There is an increased emphasis on the need for personalised, multi-pronged approach for preventing IGM recurrence, with longer follow-up care. More prospective future work in IGM research, with standardised diagnostic criteria, treatment protocols, and reporting guidelines will be important for developing treatment protocols and guidelines clinicians can adhere to in the clinical management of IGM patients.Systematic review registration: PROSPERO (CRD42022301386).

Treatment modalities for granulomatous mastitis, seeking the most appropriate treatment with the least recurrence rate: a systematic review and meta-analysis

BACKGROUND

Granulomatous mastitis (GM) is a rare, benign, inflammatory breast disease with an unknown etiology that predominantly affects women of reproductive age. The definitive treatment of GM is currently controversial; an appropriate therapeutic strategy has yet to be identified, and the disease's high recurrence rate remains. This study aims to determine the recurrence rate for each GM treatment strategy to identify the most appropriate treatment modality.

METHODS

The search for relevant articles was undertaken using three international databases, including Medline, Scopus, and Web of Science. Articles published in English until the end of 2021 evaluating the recurrence rate of GM were included. Using Stata 13.0, the pooled incidence and 95% confidence interval (CI) for the recurrence rate were determined.

RESULTS

Sixty-five eligible studies were included in our study. The recurrence rates of systemic steroid use, topical steroid use, antibiotic use, methotrexate use, observation, drainage, excision, antibiotic use and surgery, steroid use and surgery, antibiotic and steroid use, methotrexate and steroid use were 24% (95% CI: 21-27%), 11% (95% CI: 6-21%), 18% (95% CI: 14-22%), 13% (95% CI: 7-22%), 11% (95% CI: 7-17%), 65% (95% CI: 50-78%), 13% (95% CI: 10-16%), 23% (95% CI: 14-36%), 7% (95% CI: 5-11%), 11% (95% CI: 6-18%), and 4% (95% CI: 2-8%), respectively. Drainage had the highest recurrence rate, while combined methotrexate and steroid treatment had the lowest rate.

CONCLUSION

The optimal treatment strategy for GM depends on the disease's severity, consequences, and the patient's features. The study results indicate that combination therapy is preferable for minimizing the risk of relapse and reducing treatment complications.

Drug-free remission is an achievable target with immunosuppressive treatment in idiopathic granulomatous mastitis

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is a rare inflammatory breast disease, in which there is no clear established treatment algorithm. Several physicians keep away from using immunosuppressive (IS) treatments in routine clinical practice.

AIMS

This study aimed to evaluate the rates of drug-free remission of the patients with IGM in a period of 3-year follow-up.

METHODS

This retrospective study conducted with 55 biopsy-proven IGM patients, who were followed up between February, 2011, and November, 2021, in rheumatology outpatient clinic of Gulhane Training and Research Hospital. The demographic and clinical characteristics of the patients were obtained from patients' files. The 3-year follow-up data were assessed for long-term outcome analyses.

RESULTS

There were 55 female patients with a mean age of 36.8 ± 6.3 years. Fifty-four (98.1%) patients were in drug-free remission at the end of 3 years. The median duration of drug-free remission in patients receiving methotrexate (MTX), only corticosteroid (CS), and azathioprine was 19.7, 32.9, and 14.7 months, respectively. The drug-free remission duration for the patient who received cyclosporine A as IS was 28.3 months. The median duration of IS treatment was 15.8 months, and the median duration of treatment with CS and other IS combination was 6.7 months. Recurrence was observed in 4 (80%) patients without IS therapy after surgery, of whom MTX was used in 3 (75%) patients and achieved remission.

CONCLUSIONS

IS agents provide high rate of prolonged drug-free remission and should be considered a part of routine medical care of the patients with IGM.

Ozone therapy as a novel complementary therapeutic approach in refractory idiopathic granulomatous mastitis

Background

Autoimmunity may play a major role in the pathogenesis of idiopathic granulomatous mastitis (IGM). The therapeutic potential of ozone therapy has recently been shown in rheumatological diseases, and this study aimed to assess the clinical efficacy of ozone therapy (OT) in refractory IGM.

Methods

Patients with biopsy-verified IGM and incomplete response after steroid therapy (n = 47) between 2018 and 2021 were enrolled. Of these, 23 cases in cohort A had standard treatment with further steroid therapy (ST), and 24 were treated with systemic OT via autohemotherapy (AHT) in addition to steroid therapy (cohort B).

Results

The median age was 33 years (range, 24-45). Patients in cohort B had a higher complete response rate after completion of a four-month ozone therapy than those in the ST-group (OT-group, 37.5% vs. ST-group, 0%; p = 0.002). At a median follow-up of 12 months (range, 12-35), the patients treated with OT had a lower one-year recurrence in the affected breast than cases in cohort A treated with ST (OT-group, 21% vs. ST-group, 70%; p = 0.001). No significant side effects were observed in patients in cohort B related to AHT. Furthermore, OT significantly decreased the total steroid treatment duration (median week of steroid use; 26  weeks in cohort A vs. 12 weeks in cohort B; p = 0.001).

Conclusion

Systemic OT increases the complete response rate and decreases the duration of steroid treatment in patients with refractory IGM. Therefore, ozone therapy is an effective, well-tolerated, and safe novel complementary therapeutic modality.

Idiopathic Granulomatous Mastitis: Six years of experience and the current evidence in literature

Objectives

This study aimed to retrospectively describe the clinicopathological pattern and management experience of idiopathic granulomatous mastitis in women receiving care at the Royal Hospital, a tertiary care centre in Oman. The study then compared the researchers' experience with the current literature trends.

Methods

The data of patients from January 2012 to December 2017 were reviewed retrospectively, after receiving ethical approval from the Centre of Studies and Research.

Results

This retrospective study included 64 patients were confirmed to have idiopathic granulomatous mastitis. All patients were in the premenopausal phase, with only one being nulliparous. Mastitis was the most common clinical diagnosis; furthermore, half of the patients had a palpable mass. Most patients had received antibiotics during the span of their treatment. Drainage procedure was done in 73% of the patients, whereas excisional procedure was done for 38.7%. Only 52.4% of patients were able to achieve complete clinical resolution within six months of follow-up.

Conclusion

There is no standardised management algorithm due to the paucity of high-level evidence comparing different modalities. However, steroids, methotrexate and surgery are all considered to be effective and acceptable treatments. Moreover, current literature tends towards multimodality treatments planned tailored case-to-case based on the clinical context and patients' preference.

Ozone therapy restores immune dysfunction in refractory idiopathic granulomatous mastitis as a novel potential therapeutic approach

Immunological dysfunction has been suggested to play a major role in the pathogenesis of idiopathic granulomatous mastitis (IGM). We recently showed that ozone therapy was effective in patients with steroid-resistant IGM. This study assessed alterations in intracellular cytokine expression patterns in different T-lymphocyte subsets after ozone therapy in refractory IGM. Peripheral blood T lymphocyte subsets (CD8⁺ , CD4⁺ , CD4⁺ CD25⁺ CD127^- ) were analyzed via flow-cytometry for intracellular cytokine expressions IFN-γ, TNF-α, IL-10, and TGF-β before and after completion of 4-month systemic ozone therapy. Ozone therapy significantly increased the CD4⁺ IFN-γ⁺ (p = 0.032), CD4⁺ TNF-α⁺ (p = 0.028), and the CD8⁺ TNF-α⁺ (p = 0.012) T cells. In contrast, significant decreases in CD4⁺ IL-10⁺ (p = 0.047) and CD8⁺ IL-10⁺ T cells (p = 0.022) and CD4⁺ CD25⁺ CD127^-//low Treg cells secreting TGF-β (p = 0.005) were found after ozone therapy. When patients were analyzed according to the response to ozone therapy, patients with a complete remission were more likely to have increased CD3^- CD16⁺ CD56⁺ natural killer cells (p = 0.0027) and decreased CD19⁺ B lymphocytes (p = 0.046) following ozone therapy. Our results suggest that ozone therapy stimulated a T-helper-1 response associated with IFN-γ production and downregulation of TGF-β expression in CD4⁺ CD25⁺ CD127^- Treg cells. These alterations in the immune system following ozone therapy can improve wound healing and restore immune dysfunction in patients with refractory IGM.

Current Research Describing the Role of CD4+ T Lymphocyte Subsets in the Pathogenesis of Granulomatous Lobular Mastitis

Background: Granulomatous lobular mastitis (GLM) is a rare, benign, chronic inflammatory illness of the mammary gland with an unknown cause. Many scholars believe that the pathogenesis of GLM is mediated by autoimmunity. This article reviews the progress of the role of CD4+ T lymphocyte subsets in the development of GLM to explore potential therapeutic targets.Methods: Original articles from inception to October 2021 were systematically searched by two members on PubMed and China National Knowledge Infrastructure.Results: Current studies have confirmed the presence of disorders of several immune molecules in the serum and tissue microenvironment of GLM patients, including interleukin (IL) -2, IL-4, IL-6, and IL-10. This may be related to the dysregulation of Th1/Th2 and Th17/Treg balance.Conclusions: Altered expression and the malfunctioning of Th, Treg, and associated cytokines may contribute to GLM pathogenesis. Immune molecules and immune-related pathways may be potential targets and breakthroughs for future GLM treatment.