The evaluation of the efficacy of local steroid administration in idiopathic granulomatous mastitis: The preliminary results

Presentation and Management of Granulomatous Mastitis in the United States: Results of an American Society of Breast Surgeons Registry Study

BACKGROUND

Granulomatous mastitis (GM) is a benign, chronic, inflammatory disease lacking clear treatment guidelines. The purpose of this American Society of Breast Surgeons (ASBrS) prospective, multisite registry was to characterize the presentation of GM and identify treatment strategies associated with symptom resolution and optimal cosmesis.

METHODS

ASBrS members entered data into a registry on patient demographics, treatment, symptoms, and cosmesis over a 1-year period. Initial symptoms were graded as mild, moderate, or severe. The Chi-square test and logistic regression were used to identify factors related to symptom improvement and cosmesis.

RESULTS

Overall, 112 patients with a mean age of 36 years were included. More patients were Hispanic (49.1%) and from the Southwest (41.1%), and management included observation (4.5%), medical (70.5%), surgical (5.4%), or combination treatment (19.6%). Immunosuppression was used in 83 patients (74.1%), including 43 patients who received intralesional steroid injections. Patients with severe symptoms were more likely to undergo surgical intervention compared with those with mild or moderate symptoms (21.4% vs. 0% and 7.5%, respectively; p = 0.004). Within 1 year, 85 patients (75.9%) experienced symptom improvement and/or resolution at a median of 3 months. Receipt of immunosuppressive therapy was predictive of improvement or resolution at 1 month (odds ratio 4.22; p = 0.045). One-year physician-assessed cosmesis was excellent or good for 20/35 patients (57.1%) and was not associated with type of treatment or symptom severity.

CONCLUSION

Although GM can have a protracted course, the majority of patients in this registry resolved within 1 year, with good cosmetic result. Treatment with immunosuppression appears to be most beneficial, and a symptom-based algorithm may be helpful to guide treatment.

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).

The Effect of Local Steroid Administration on Idiopathic Granulomatous Mastitis: A Systematic Review andMeta-Analysis

INTRODUCTION

Idiopathic granulomatous mastitis (IGM) is a rare, benign inflammatory breast disease. Corticosteroids and surgery are the primary treatment options, and a growing number of publications have shown the effectiveness of local steroid administration (intralesional injection and topical corticosteroids). However, less is known about the specific details and effects of this treatment approach. The purpose of this meta-analysis was to summarize the details and evaluate the efficacy of local steroid administration for IGM.

METHODS

The PubMed, Embase, Cochrane Library, and SinoMed databases were systematically searched from inception to July 2023 to identify relevant randomized controlled trials. The quality of the included studies was assessed, and meta-analysis and subgroup analysis were conducted to obtain the pooled effect sizes of the outcomes of interest.

RESULTS

Eight trials comprising 613 patients were included. Local steroid administration included intralesional injection and topical steroid ointment, and control groups were mainly given systemic therapy (oral steroid) and surgical treatment. The meta-analysis showed that local steroid administration had a significant effect on the response rate (risk ratio [RR] = 1.35, 95% CI = [1.14-1.59], P = 0.0004). The incidence of side effects was also lower than that of systemic treatment (RR = 0.24, 95% CI = [0.13-0.43], P＜0.0001). There was no difference in the recurrence rate (RR = 0.8, 95% CI = [1.42-1.51], P = 0.48).

CONCLUSIONS

Local steroid administration can increase the RR and decrease the incidence of side effects for IGM patients. There is no significant difference in the recurrence rate between the local steroid administration group and the control group. Further studies are needed to identify the effect in different stages and among pregnant women.

Framework and guide for intralesional steroid injections in idiopathic granulomatous mastitis

PURPOSE

Literature on how to perform intralesional steroid injections, a valuable therapy for idiopathic granulomatous mastitis (IGM), is limited. This technical note offers a detailed technical guide on intralesional steroid injections for IGM and provides a framework for long-term follow-up.

METHODS

Ultrasound characterization of IGM severity considering breadth, depth, and ancillary findings was used to guide steroid dosing and injection frequency. Clinical and sonographic breast diagrams were designed for accurate longitudinal tracking of IGM. A step-by-step guide for ultrasound-guided IGM aspirations and intralesional steroid injections was developed.

RESULTS

A detailed approach for ultrasound-guided IGM interventions with clinical and sonographic breast diagrams for longitudinal follow-up is now in practice.

CONCLUSIONS

The treatment approach described provides a framework for multidisciplinary treatment of IGM and offers insights that may contribute to the ongoing development and improvement of management strategies for this challenging disease.

Local steroid injection in severe idiopathic granulomatous mastitis as a new first-line treatment modality with promising therapeutic efficacy

Background

Intralesional steroid injection has recently evolved as a novel treatment modality for localized idiopathic granulomatous mastitis (= IGM). We aimed to explore the therapeutic efficacy of local steroid injections (LSI) in patients with severe IGM.

Methods

Fifty-one patients diagnosed with severe IGM were included in the study and treated with either local steroid injection (LSI) alone (n = 25) or combined LSI with systemic oral steroid treatment (OST) (n = 26). The local steroid injection protocol included an intralesional triamcinolone acetonide injection into the palpable granulomas every 4-week, and topical administration of steroid-containing pomades twice a day on the affected surface of the breast. Patients with a combined LSI and OST received low-dose oral methylprednisolone (<16 mg).

Results

Patients with LSI alone required more LSI applications than those in the combined LSI with OST group (LSI: 5 ± 2.9; vs. LSI/OST: 3.5 ± 2.5; p = 0.080) to obtain an effective optimum therapeutic response. At a median of 12 months (range, 4-42), no difference was found in complete response rates between patients in the LSI group and the combined LSI group with OST (52 vs. 53.9%, p = 0.999). However, steroid-related systemic side effects were lower in the LSI alone group (p < 0.008).

Conclusion

Local steroid injection could be considered as the first-line treatment in patients with severe IGM until a therapeutic response has been obtained either as the sole treatment modality or combined with oral steroids. Compared with systemic oral steroid therapy, local steroid administration can be considered a new treatment modality with fewer side effects.

Combining intralesional steroid injection with oral steroids in patients with idiopathic granulomatous mastitis

Idiopathic granulomatous mastitis (IGM) is a chronic inflammatory breast disease. Currently, there is no international standard for steroid use in IGM, particularly for intralesional steroid injections. This study aimed to determine whether patients with IGM who received oral steroids could benefit from intralesional steroid injection. We analyzed 62 patients with IGM whose main clinical presentation was mastitis masses and who received preoperative steroid therapy. Group A (n = 34) received combined steroid treatment: oral steroids (starting dose, 0.25 mg/kg/d; tapered off) and intralesional steroid injection (20 mg per session). Group B (n = 28) received oral steroids only (starting dose, 0.5 mg/kg/d; tapered off). Both groups underwent lumpectomy at the end of steroid treatment. We analyzed the preoperative treatment time, preoperative mass maximum diameter reduction rate, side effects, postoperative satisfaction, and rate of IGM recurrence. The mean age of the 62 participants was 33.6 ± 2.3 (range, 26-46) years, and all had unilateral disease. We found that oral steroids combined with intralesional steroid injection yielded better therapeutic effects than did oral steroids alone. The median maximum diameter reduction of the breast mass was 52.06% in group A and 30.00% in group B (P = .002). Moreover, the use of intralesional steroids reduced the duration of oral steroid use; the median durations of preoperative steroid therapy were 4 and 7 weeks in groups A and B, respectively (P < .001). Group A patients were more satisfied (P = .035) with the postoperative results, including postoperative appearance and function. No statistically significant between-group differences were noted regarding side effects and recurrence rates. Preoperative administration of oral steroids combined with intralesional steroid injection yielded better therapeutic effects than did oral steroids alone and may be an effective future treatment for IGM.

Comparison of the Efficacy of Systemic Versus Local Steroid Treatment in Idiopathic Granulomatous Mastitis: A Cohort Study

INTRODUCTION

Steroid therapy is known to be effective against granulomatous mastitis. We aimed to compare the efficacy of local versus systemic steroid administration in patients with idiopathic granulomatous mastitis.

MATERIALS AND METHODS

This prospective cohort study included 58 patients who had either local (n = 42) or systemic (n = 16) treatment due to granulomatous mastitis between 2015 and 2019. Recurrence rates were determined as per ultrasound and magnetic resonance imaging examinations and the rate of side effects was evaluated as per patient complaints and physical examinations at the end of a 2-year follow-up period.

RESULTS

Median doses of 140 mg and 3810 mg were administered to the local and systemic group, respectively. Six (14.3%) patients in the local treatment group and 13 (81.3%) in the systemic treatment group had steroid-related side effects. The local treatment group had significantly fewer side effects than the systemic treatment group (P < 0.001). The recurrence rates were similar in both groups (P > 0.05).

CONCLUSIONS

Local steroid injection was as effective as systemic steroid therapy. Compared to systemic therapy, local steroid administration can be considered as a new therapeutic protocol with a lower dose and side effect rate.

Management of granulomatous lobular mastitis: an international multidisciplinary consensus (2021 edition)

Granulomatous lobular mastitis (GLM) is a rare and chronic benign inflammatory disease of the breast. Difficulties exist in the management of GLM for many front-line surgeons and medical specialists who care for patients with inflammatory disorders of the breast. This consensus is summarized to establish evidence-based recommendations for the management of GLM. Literature was reviewed using PubMed from January 1, 1971 to July 31, 2020. Sixty-six international experienced multidisciplinary experts from 11 countries or regions were invited to review the evidence. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Experts discussed and concluded 30 recommendations on historical definitions, etiology and predisposing factors, diagnosis criteria, treatment, clinical stages, relapse and recurrence of GLM. GLM was recommended as a widely accepted definition. In addition, this consensus introduced a new clinical stages and management algorithm for GLM to provide individual treatment strategies. In conclusion, diagnosis of GLM depends on a combination of history, clinical manifestations, imaging examinations, laboratory examinations and pathology. The approach to treatment of GLM should be applied according to the different clinical stage of GLM. This evidence-based consensus would be valuable to assist front-line surgeons and medical specialists in the optimal management of GLM.

Treatment Results of Intralesional Steroid Injection and Topical Steroid Administration in Pregnant Women with Idiopathic Granulomatous Mastitis

Objective

Idiopathic granulomatous mastitis (IGM) is an inflammatory and chronic benign breast disease that has proven difficult to diagnose and treat. Since most treatment modalities cannot be used in pregnant patients, the choice of treatment is more difficult and the need for surgery is more pressing. In this first and innovative study, we assess the results of local corticosteroid therapy of IGM in pregnant women.

Materials and Methods

Pregnant women with IGM were evaluated between June 2017 and May 2019. The six pregnant women were treated using intralesional steroid injections and topical steroid administration. The treatment response was evaluated, both clinically and radiologically, at the end of 2 weeks and once more at the end of 1 month.

Results

The median patient age was 26 years. The mean duration of complaints was 4.3 months. The median number of children was 2, and the mean breastfeeding time was 41 months. The predominant complaints at onset were a breast mass or local pain and inflammation in four (66.7%) patients and a breast mass with pain and without signs of local skin inflammation in two (33.3%) patients. Diagnosis was made using a tru-cut biopsy in two patients, and with an incisional biopsy in four patients who had abscess drainage and fistulation to the skin. Five (83.3%) patients achieved a complete response, and one (16.7%) patient responded only partially after the first course of treatment. A second course of treatment was given to the patient with partial response. All patients achieved complete response at the end of the second course of treatment. The mean follow-up time was 19.5 months. During the follow-up period, one patient experienced a recurrence at 4 months after giving birth, and she then received a third course of treatment. Topical and systemic side effects of the corticosteroids were not observed in any patient.

Conclusion

While the state of pregnancy generally precludes the use of most drugs, the use of local corticosteroid in the treatment of IGM is effective in terms of treatment response, treatment duration, need for surgery, and reduced recurrence and side effects.