Idiopathic granulomatous lobular mastitis - report of 43 cases from iran; introducing a preliminary clinical practice guideline

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.

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).

Ultrasound-guided microwave ablation for the treatment of idiopathic granulomatous mastitis: comparison with surgical excision

BACKGROUND

Idiopathic granulomatous mastitis (IGM) results in notable clinical symptoms and breast deformity. This study aimed to evaluate the clinical feasibility of microwave ablation (MWA) for the treatment of IGM through comparison with surgical excision.

METHODS

From June 2016 to December 2020, a total of 234 consecutive patients admitted to the hospital were retrospectively included in this study. IGM was pathologically confirmed via breast biopsy in all included patients. These patients were divided into the MWA group (n = 91) and surgical group (n = 143) based on the type of treatment. Patients in both groups received oral prednisone prior to intervention. The clinical remission rate, recurrence rate, operative pain, complications, and BREAST Q score were compared between the two groups.

RESULTS

There were 340 lesions in the MWA group, and 201 lesions in the surgical group were ultimately included. Significant differences in the complete remission rate (96.7% vs. 86.7%, p = 0.020), recurrence rate (3.3% vs. 13.3%, p = 0.020), operation time (48.7±14.6 min vs. 68.1±36.4 min, p < 0.001), postoperative pain (p < 0.001) and postoperative BREAST Q score (p < 0.001) were observed between the MWA and surgical groups.

CONCLUSIONS

Microwave ablation is feasible for the treatment of IGM, due to its high curative rate and low recurrence rate. Because of the minimal invasiveness of MWA and sufficient preservation of the gland and contour of the breast, patients are more satisfied with the appearance of the breast. Therefore, for patients with complex conditions requiring surgery, MWA is a good alternative treatment.

Factors Affecting Recurrence of Idiopathic Granulomatous Mastitis: A Systematic Review

Idiopathic granulomatous mastitis is a rare and benign disease that primarily affects young women of reproductive age. Various factors have been suggested as possible causes, including pregnancy, breastfeeding, history of taking birth control pills, hyperprolactinemia, smoking, and history of trauma. Due to unknown etiology, opinions on its treatment have varied, resulting in differing recurrence rates and side effects. Therefore, conducting a comprehensive systematic review and meta-analysis can aid in understanding the causes and recurrence of the disease, thereby assisting in the selection of effective treatment and improving the quality of life. A systematic literature review was conducted using predefined search terms to identify eligible studies related to risk factors and recurrence up to June 2022 from electronic databases. Data were extracted and subjected to meta-analysis when applicable. A total of 71 studies with 4735 patients were included. The mean age of the patients was 34.98 years, and the average mass size was 4.64 cm. About 3749 of these patients (79.17%) were Caucasian. Patients who mentioned a history of pregnancy were 92.65% with 76.57%, 22.7%, and 19.7% having a history of breastfeeding, taking contraceptive pills, and high prolactin levels, respectively. Around 5.6% of patients had previous trauma. The overall recurrence rate was 17.18%, with recurrence rates for treatments as follows: surgery (22.5%), immunosuppressive treatment (14.7%), combined treatment (14.9%), antibiotic treatment (6.74%), and observation (9.4%). Only antibiotic and expectant treatments had significant differences in recurrence rates compared to other treatments (p value = 0.023). In conclusion, factors such as Caucasian race, pregnancy and breastfeeding history, and use of contraceptive hormone are commonly associated with the disease recurrence. Treatment should be tailored based on symptom severity and patient preference, with surgery or immunosuppressive options for recurrence.

LC/MS-based untargeted lipidomics reveals lipid signatures of nonpuerperal mastitis

BACKGROUND

Nonpuerperal mastitis (NPM) is a disease that presents with redness, swelling, heat, and pain during nonlactation and can often be confused with breast cancer. The etiology of NPM remains elusive; however, emerging clinical evidence suggests a potential involvement of lipid metabolism.

METHOD

Liquid chromatography‒mass spectrometry (LC/MS)-based untargeted lipidomics analysis combined with multivariate statistics was performed to investigate the NPM lipid change in breast tissue. Twenty patients with NPM and 10 controls were enrolled in this study.

RESULTS

The results revealed significant differences in lipidomics profiles, and a total of 16 subclasses with 14,012 different lipids were identified in positive and negative ion modes. Among these lipids, triglycerides (TGs), phosphatidylethanolamines (PEs) and cardiolipins (CLs) were the top three lipid components between the NPM and control groups. Subsequently, a total of 35 lipids were subjected to screening as potential biomarkers, and the chosen lipid biomarkers exhibited enhanced discriminatory capability between the two groups. Furthermore, pathway analysis elucidated that the aforementioned alterations in lipids were primarily associated with the arachidonic acid metabolic pathway. The correlation between distinct lipid populations and clinical phenotypes was assessed through weighted gene coexpression network analysis (WGCNA).

CONCLUSIONS

This study demonstrates that untargeted lipidomics assays conducted on breast tissue samples from patients with NPM exhibit noteworthy alterations in lipidomes. The findings of this study highlight the substantial involvement of arachidonic acid metabolism in lipid metabolism within the context of NPM. Consequently, this study offers valuable insights that can contribute to a more comprehensive comprehension of NPM in subsequent investigations.

TRIAL REGISTRATION

Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine (Number: 2019-702-57; Date: July 2019).

Comparative study of ultrasound-guided microwave ablation and traditional surgery in the treatment of plasma cell mastitis: a multicenter study

Background

Plasma cell mastitis (PCM) is a benign breast disease that is refractory and difficult to cure. We integrated microwave ablation into the treatment of PCM to compare the clinical value of ultrasound-guided microwave ablation and traditional surgery in the treatment of PCM.

Methods

A total of 68 patients with PCM who were admitted to 3 centers (Zhejiang Cancer Hospital, Hebei Province Hospital of Traditional Chinese Medicine, and Yantai Affiliated Hospital of Binzhou Medical university) from January 2017 to June 2019 were selected. All patients were diagnosed with PCM after pathological and clinical manifestations. Among these, 38 cases were treated with ultrasound-guided microwave ablation, and 30 cases were treated with traditional surgery. The operation time, hospitalization time, incision healing, intraoperative blood loss, postoperative pain degree, evaluation of breast shape effect, time taken for postoperative lesion disappearance, effective rate, and recurrence were recorded in the follow-up, and the clinical efficacy was compared and observed.

Results

The effective rate of the ablation group was 86.8% (33/38), that of the operation group was 46.7% (14/30), and the difference was statistically significant (95% CI: 2.311-24.618; P<0.05). The average time of the lesion completely disappearing was 75.55±43.59 days in the ablation group and 103.87±45.98 days in the operation group, and the difference was statistically significant (P<0.05). The hospital stays, operation time, and intraoperative blood loss of patients in the ablation group were less than those of the operation group, and the difference was statistically significant (95% CI: -10.69 to -6.27, 95% CI: -77.06 to -51.26, and 95% CI: -21.54 to -13.64; P<0.05). The postoperative pain scoring, operative incision healing at 14 days after the operation, and breast appearance evaluation after treatment in the ablation group were better than those of the operation group, and the difference was statistically significant (P<0.05).

Conclusions

Compared with traditional surgery, ultrasound-guided microwave ablation is a more effective treatment option for PCM.

Management of idiopathic granulomatous mastitis: a prospective study

INTRODUCTION

Idiopathic granulomatous mastitis (IGM) is an evolving problem with varied presentation. No definite treatment guidelines are available at present that may reduce rate of recurrence. Current evidence suggests a ductal pathology behind IGM, which leads to periductal mastitis, leakage and sinus/fistula formation. Thus, excision of the sinus/fistulous tract with en-bloc wide local excision (WLE) of the lesion could be curative. The objective of this study was to look for the basic aetiology of IGM and evaluate the effectiveness of WLE with total or partial duct excision as a curative approach.

METHODS

An institutional prospective comparative study was conducted over 4 years (2015-2019), in which 59 cases of IGM were randomly divided into three groups. After necessary investigations, patients in group A received steroid therapy, those in group B received WLE and patients in group C received WLE with total or partial duct excision as the mode of treatment. Postoperative follow-up was between 6 months and 3 years.

RESULTS

Histopathological examination (HPE) was found to be the most suitable diagnostic procedure. Patients in group B showed the highest rate of recurrence (73.6%), followed by group A (35.0%) and group C (5.0%). Patients in group C had a significantly lower chance of recurrence compared with both group A and group B (p < 0.05). HPE reports of excised ducts from patients in group C showed ductal disruption and leakage along with periductal granuloma in 70% of cases.

CONCLUSIONS

The presence of duct granuloma indicates the association of ductal pathology in IGM. IGM is therefore a disease of the mammary ducts and en-bloc duct excision is curative in non-responding cases.

Idiopathic Granulomatous Mastitis as an Unusual Cause of Erythema Nodosum in a Malagasy Woman

Introduction

Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory disease. Neoplastic and infectious etiologies must be ruled out. IGM is a diagnostic challenge for countries with high tuberculosis endemicity like Madagascar since it may clinically and radiologically mimic breast tuberculosis. We report a case of IGM associated with erythema nodosum in a Malagasy.

Case Report

A 29-year-old primiparous woman came to a dermatological consultation for typical erythema nodosum lesions that appeared one month after a breast swelling. She had no particular medical history. Examination revealed typical erythema nodosum lesions on the legs, voluminous tender mass in the right breast. Bacteriological samples and tuberculosis test were negative. Imaging showed mastitis on the right breast with no evidence of malignancy. Histology revealed a non-caseating granulomas on the lobule of the right breast. As part of an etiological work-up, COVID-19 serology was performed with a positive IgG antibody. The diagnosis of IGM associated with erythema nodosum was evocated. The evolution was favorable under systemic corticosteroid therapy.

Discussion

The cause of this uncommon lesion remains obscure. The extramammary localizations such as erythema nodosum and arthralgia suggest an autoimmune origin. This pathogenesis is also reinforced by a good response to systemic immunosuppression. In our patient, the etiological assessment of the mastitis revealed a chronic infection with SARS-CoV-2. Histopathology is the gold standard for the IGM diagnosis which demonstrates a lobulocentric granulomas without caseous necrosis. Oral corticosteroid therapy is the initial choice of treatment.

Conclusion

Now, with several cases of concomitant IGM and EN reported, dermatologists should be aware that erythema nodosum can be one of the presenting signs of IGM, since the two conditions appear to be associated. The particularity of our case lies in the incidental discovery of SARS-CoV-2 infection. Is a chronic granulomatous disease associated with SARS-CoV-2 infection, a coincidence?

Risk Factors and the Role of the Albumin-to-Globulin Ratio in Predicting Recurrence Among Patients with Idiopathic Granulomatous Mastitis

Background

Idiopathic granulomatous mastitis (IGM) is a rare inflammatory disease of the breast with a high recurrence rate. The serum albumin to globulin ratio (AGR) is a relatively novel biomarker in inflammatory diseases, and one whose role in the recurrence of IGM remains unknown. This study primarily investigated the potential risk factors for IGM recurrence and whether AGR can be used as a predictive factor.

Methods

Patients diagnosed with IGM from pathology reports between 2016 and 2021 were enrolled in the study, and their medical records were analyzed retrospectively. The patients were divided into two groups – recurrence and non-recurrence. Clinical, demographic characteristics, and laboratory parameters were compared.

Results

Eighty-five patients were included in the study, recurrence being detected in 16 (18.8%) of these, with a median follow-up time of 39.99±18.93 months. No relationship was determined between childbearing, breastfeeding, disease severity, or therapeutic approaches and IGM recurrence. While AGR was significantly lower in the recurrence group (p < 0.001), neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) results were comparable in the two groups (p = 0.472 and p = 0.421, respectively). Multivariate analysis identified low AGR (odds ratio (OR): 50.7, 95% CI 5.93–434.1 P < 0.001) and smoking (OR: 4.45, 95% CI 1.04–18.9 P = 0.044) as independent risk factors for IGM recurrence.

Conclusion

The study findings indicated that AGR at a cut-off value of ≤1.179 at diagnosis and smoking exhibited a remarkable performance in predicting the recurrence of IGM. Developing new risk stratification systems for IGM recurrences and using AGR in these classifications may increase the success of treatment.

Trial Registration

This study was registered with ClinicalTrials.gov, NCT05409586.

Idiopathic granulomatous mastitis: experience at a New York hospital

INTRODUCTION

Idiopathic granulomatous mastitis (IGM) often mimics breast cancer. Presentation includes pain, palpable mass, suppuration or suspicious imaging. Widely reported in Asia and the Middle East, IGM is diagnosed after excluding specific granulomatous mastitis (SGM). Aetiology remains unknown. Lactation, prolactinaemia, ethnicity, autoimmune disease and Corynebacteria are associated. Treatment is controversial and the prevalence rising. Surgery and non-operative treatments including antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), steroids, methotrexate and observation have advocates.

METHODS

A retrospective chart review of 63 patients with IGM from 2008 to 2018 was undertaken focusing on birthplace, age, clinical presentation, wound cultures, imaging, treatments and outcomes.

RESULTS

Sixty-one of 63 patients were Hispanic; 53 were Mexican-born women aged 23-46. Clinical presentation included pain, painful mass, painless mass, suppuration and abnormal imaging. Some 31/61 ultrasound examinations and 17/33 mammograms were deemed Breast Imaging Reporting and Data System (BI-RADS) score 4 or 5. Management included antibiotics (43), incision and drainage (24), NSAIDs (29), steroids (8), lumpectomy (18) and observation (12). Some 12/20 patients with painless masses resolved with observation, 3 received NSAIDs, 2 received steroids and 3 underwent lumpectomies. Antibiotics resolved 8/43 cases, 5 needed incision and drainage, 26 received NSAIDs, 6 received steroids and 5 underwent lumpectomies. Nineteen patients had indolent disease or recurrence.

CONCLUSIONS

Excluding malignancy is critical, treatment challenging and recurrence common in IGM. A preponderance of patients were Mexican-born, similar to other reports from the USA. Over 50% of IGM cases had suspicious BI-RADS scores. Best management remains a challenge and ranges from observation to lumpectomy.

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.

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.

A rheumatologic approach to granulomatous mastitis: A case series and review of the literature

AIM

Idiopathic granulomatous mastitis (IGM) is an enigmatic inflammatory breast disorder. IGM responds to immunomodulatory treatment and may be associated with systemic manifestations such as arthritis and erythema nodosum. These patients are increasingly referred to rheumatologists for management, but IGM is rarely discussed in the rheumatology literature. The objective of this report is to familiarize rheumatologists with the treatment and systemic manifestations of IGM. We report here a case series of IGM at our institution, and a literature review of IGM treated with methotrexate (MTX).

METHOD

Patients with IGM at our institution were identified and described using a retrospective chart review. A literature review of PubMed and Google Scholar identified studies of IGM patients treated with MTX.

RESULTS

We identified 28 IGM patients at our institution. Inflammatory arthritis/arthralgia were present in four patients (14%), and five patients (18%) had erythema nodosum. Patients treated with MTX had the highest rates of relapse-free remission; relapse-free remission occurred in four of the five (80%) MTX-treated patients, compared with 5 of 12 (42%) patients treated with steroids alone, and two or three (66%) patients treated with steroids and surgery. In the literature review, 116 patients treated with MTX were identified, and the rate of relapse-free remission ranged from 58% to 100%. Arthritis/arthralgia and erythema nodosum were more common at our institution than reported in the literature.

CONCLUSION

Methotrexate is a promising treatment for IGM. Arthritis/arthralgias and erythema nodosum may be under-recognized when IGM patients are managed outside rheumatology. Prospective studies are needed to characterize clinical features and optimum treatment of IGM.

Idiopathic Granulomatous Mastitis: Etiology, Clinical Manifestation, Diagnosis and Treatment

Idiopathic granulomatous mastitis (IGM) is a rare form of chronic inflammatory breast disease. Although it is a benign breast lesion, it may be sometimes difficult to distinguish from breast cancer. The cause of IGM is unknown, but may be associated with autoimmunity, abnormal hormone levels and infection. While the clinical manifestations of IGM involve various manifestations of inflammation, the diagnosis is principally established by histopathology, characterized by non-caseating granulomas and microabscess formation centered on the breast lobules. Therapeutic options for IGM range from observation to various medical treatments, such as steroids, immunosuppressants, and antibiotics, to surgical intervention, particularly if secondarily infected. Given that the controversy on etiology and treatment choices, we accomplished the present review through reviewing IGM-related literature published in 'Pubmed' and 'Web of science' databases during 1997 to 2020, aiming to provide the basis for rational clinical diagnosis and treatment.

Mastitis, Breast Abscess, and Granulomatous Mastitis

Breastfeeding is immunoprotective and World Health Organization recommends exclusive breastfeeding for about six months with continuation of breastfeeding for one year or longer as mutually desired by mother and infant. But the target for duration of exclusive breastfeeding has not been reached in a significant number of women. It may be due to inflammatory breast disease such as milk stasis or lactational mastitis.In this chapter we discuss the most common complications of breastfeeding including milk stasis, mastitis, and breast abscess. Also idiopathic granulomatous mastitis, a less common condition, is discussed due to its confusing characteristics and not universally-accepted treatment strategies .Breastfeeding mastitis is inflammation of the breast that can be infectious or non-infectious. With proper diagnosis and treatment of this condition, more severe complications like breast abscess could be avoided, so that breastfeeding could be continued in some circumstances.

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.

[Idiopathic granulomatous mastitis associated with erythema nodosum]

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is a rare, chronic, granulomatous, inflammatory disorder with potentially misleading clinical and radiological features. IGM is diagnosed after exclusion of infectious or tumoral diseases. Herein we report a case of erythema nodosum associated with IGM, which serves as a reminder that erythema nodosum may constitute an extra-mammary sign of IGM.

PATIENTS AND METHODS

A 36-year-old nulliparous woman presented with fever and skin rash at our dermatology clinic at the North Franche-Comté hospital in July 2017. Symptoms had occurred 2 days previously. The patient had a fever of 38.8°C and typical erythema nodosum on the limbs. Physical examination showed an irregular, inflammatory, abscessed mass measuring 20cm with multiple shrinkage zones that had been developing for 4 weeks and for which breast examinations were being performed. Laboratory tests showed an inflammatory state (CRP 155mg/mL, WBC 14.6×109/L), other tests (serum electrolytes and calcium, hepatic and renal tests, Streptotest, T-spot, HIV, HBV, HCV serology, anti-streptolysin, anti-streptodornase, local microbiology samples, antinuclear antibodies, soluble antigens antibodies, hemocultures, angiotensin-converting-enzyme and chest x-rays) were normal. Microbiology investigations were negative. Mammography revealed invasive mastitis. Breast sample biopsies showed giant cell granulomas without caseous necrosis or tumor cells, and histochemical staining (PAS, Ziehl, Grocott, Gram) was negative. The final diagnosis was of IGM associated with erythema nodosum. Symptoms rapidly improved with oral steroids.

DISCUSSION

As reported herein, erythema nodosum may be associated with IGM and support the diagnosis thereof. This association is rare, with fewer than 30 case reports described in the literature. IGM is an uncommon benign disorder of the breast that can mimic two frequent breast disorders: breast carcinoma and breast abscess. It usually occurs in young sexually active women. It appears as a tumor with an inflammatory solid painful mass, with nipple and skin retraction, occasionally with abscesses and accompanied by homolateral axillary lymphadenopathies. Radiologic findings are usually not specific for or suggestive of cancer. The histopathological picture of IGM is characterized by the presence of multinucleated giant cells and epithelioid histiocytes forming non-caseating granulomas around lobules. Minor ductal and periductal inflammation is usually present. IGM is rarely associated with autoimmune system manifestations, especially erythema nodosum, arthritis, episcleritis or hidradenitis suppurativa. Although the physiopathology of IGM remains unclear, this case serves as additional evidence that the etiology of IGM is of autoimmune origin. While there is no recommendation for the treatment of IGM, oral steroids remain the cornerstone of therapy.

CONCLUSION

We report a case of IGM associated with erythema nodosum. Dermatologists must be aware of this association.

Clinical Presentations of Breast Disorders in Pregnancy and Lactation

The breast tissue undergoes significant physiological change during pregnancy and lactation. These changes can give rise to some unique disorders during pregnancy , puerperium and lactation or exaggerate pre-existing conditions. Clinical examination becomes less reliable due to textural change and density of breast tissue as a result of hormonal changes. The main symptoms during pregnancy and lactation are breast pain, mastitis, lactational abscess, breast lump, and blood- stained nipple discharge.Lactational mastitis/ abscess must be treated without delay. Open incision and drainage of lactational abscess is rarely required, any lactational abscess should be treated with appropriate antibiotics and ultrasound guided aspiration of the pus.Any breast lump during pregnancy and lactation should be investigated with triple assessment. Pregnancy associated breast cancer (PABC ) must be ruled out. The choice of investigations and treatment needs careful consideration. While ultrasound is the investigation of choice, mammography can be performed with abdominal shielding if malignancy is suspected. Core biopsy is necessary for evaluation of any breast pathology but it comes with risk of infection, bleeding, hematoma and even milk fistula.The treating clinical specialist must be aware of certain unusual unique clinical conditions in pregnancy and lactation including accessory axillary breast tissue, gigantomastia and Raynaud's phenomenon.

Granulomatous Mastitis and Factors Associated with Recurrence: An 11-Year Single-Centre Study of 113 Patients in Singapore

BACKGROUND

Granulomatous mastitis (GM) is an inflammatory breast disease of unknown aetiology. It poses diagnostic and therapeutic challenges with myriad forms of clinical presentation, varying results to treatments and propensity to recur. This study aims to look at clinical and treatment factors that predispose to recurrence of GM.

METHODS

We performed a retrospective review of 113 patients in our unit with histologically proven GM from 2006 to 2016. Demographic, clinical, treatment and outcomes data were collected and analysed.

RESULTS

Eighty-nine patients were treated with antibiotics (78.8%), 79 (69.9%) with steroids and 23 (20.4%) patients underwent surgery. Twenty (17.7%) patients had recurrence. Patients who presented with inflammatory signs and symptoms had increased odds of having subsequent recurrence: skin changes (1.50), pain (2.00), fistula (4.39) and antibiotic treatment (6.65). Four patients (20%) with recurrence had positive bacterial cultures. All 4 grew Corynebacterium. Patients with Corynebacterium infection had a 2.64 times higher risk of recurrence. Surgery did not preclude recurrence. There was a 70% (7/10) penicillin resistance rate in our patients with positive cultures for Corynebacterium.

CONCLUSION

Initial presentation with inflammatory signs and symptoms may confer increased risk of recurrence, warranting closer monitoring. Corynebacterium infection may play a part as a causative factor and risk factor for recurrence. Non-penicillin antibiotics should be considered as first-line antibiotics for patients presenting with inflammatory changes. Further prospective studies with larger patient populations might reveal information on the aetiology of GM and result in the development of a more standardized and effective treatment regimen.

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: A systematic review of 3060 patients

Idiopathic granulomatous mastitis is a rare benign breast disease. A systematic review was designed. Clinical and therapeutic characteristics were analyzed. Human Development Index (HDI) was used to define two groups of study: group A (very high and high HDI) and group B (medium and low HDI). Corticosteroid therapy was done in 69% group A and 78% group B. Surgery was done in 63% in group A and 83% in group B. Antibiotics were used in 68% group A and 88% group B. There is no consensus about optimal treatment for granulomatous mastitis.

Imaging features of granulomatous mastitis in 36 patients with new sonographic signs

PURPOSE

Idiopathic granulomatous mastitis is a rare relapsing benign inflammatory breast disease with unknown etiology. Its clinical features and imaging signs may mimic inflammatory breast cancer or some other inflammatory breast disease. This may interfere with correct and timely diagnosis and thus impose an additional burden on the costs of diagnosis and therapy, as well as patient anxiety. We aimed to characterize the imaging findings of this disease and introduce two new imaging signs.

MATERIALS AND METHODS

This prospective study examined 36 patients with imaging and a clinical diagnosis of mastitis granulomatosis who were untreated and then confirmed by pathology. Demographic information, clinical data, imaging findings, and signs were recorded.

RESULTS

The age range of the patients was 22-60 years with an average of 36 years. Most of the patients (78%) were at reproductive age. None of the patients had a family history of granulomatous mastitis. Most patients with granulomatous mastitis (89%) lived in regions with low socioeconomic status. For most patients, sonography indicated a heterogeneous hypoechoic mass with irregular shape and ill-defined margin (26 cases; 72.2%). Focal asymmetry (36%) and obscured mass (36%) were the most common mammographic findings. Two signs of duct ectasia containing secretion and high-flow pseudocyst appearance were described.

CONCLUSION

Mammographic and ultrasound findings can highly suggest a diagnosis of granulomatous mastitis in an appropriate clinical context.

Granulomatous lobular mastitis associated with ductal carcinoma in situ of the breast

The association of granulomatous lobular mastitis and carcinoma of the breast is very infrequent. We present the case of a 44-year-old woman with concurrent granulomatous lobular mastitis with coryneform bacteria and ductal carcinoma in situ in the same breast.

Granulomatous mastitis: etiology, imaging, pathology, treatment, and clinical findings

PURPOSE

To outline the demographics, clinical presentation, imaging features, and treatment modalities observed among a series of patients diagnosed with biopsy-proven granulomatous mastitis (GM).

METHOD

Following approval by institutional review board, retrospective chart review was performed on patients with biopsy-proven granulomatous mastitis at our institution in the period from January 2013 until October 2017.

RESULTS

A total of 90 patients were identified: 87 women and 3 men. The mean age was 35 years, mostly women in their reproductive age. In our study, patients with GM were more likely to be Hispanic compared to the general population. Sixty-three percent of patients were within 5 years of previous pregnancy. Painful palpable mass-like lesion was the most common physical finding. Breast ultrasound (US) was performed in all patients, and most commonly showed a hypoechoic irregular-shaped mass. Mammography (MG) showed asymmetry or irregular mass as the main finding. Definitive diagnosis was obtained by imaging-guided core needle biopsies in 94.4%. Conservative management was preferred, and only one patient underwent surgery.

CONCLUSION

Although clinical and radiological findings of patients with GM may mimic those of breast carcinoma, our study showed that women of childbearing age, especially among Hispanic ethnicity with a recent history of pregnancy or high prolactin level and newly tender mass-like lesion, in addition to new focal asymmetry on mammogram and heterogeneous hypoechoic irregular-shaped mass on ultrasound exam, should raise concern for GM. Non-invasive approach and clinical follow-up were the preferred treatment method.

Scoring Idiopathic Granulomatous Mastitis: An Effective System for Predicting Recurrence?

Objective

Idiopathic granulomatous mastitis is a breast disease without a definitive etiology. There are no definitive classifications, scoring systems or certitudes. The aim of this study is to define the factors related to the recurrence and design a scoring system.

Material and Methods

Patients who were admitted to the general surgery department with symptoms of granulomatous mastitis were evaluated by ultrasonography and underwent antibiotic therapy. Granulomatous mastitis is diagnosed by core biopsy and treated with steroid therapy. Patients without improvement underwent surgery and were included in the study. In total, 53 patients were included in the study. There were 8 recurrent cases. Factors related with recurrences were defined.

Results

Number of births over 2, duration of lactation more than 18 months, body mass index greater than 31, having fistula in physical examination, abscess collection in ultrasonographic examination, and luminal inflammation score over 2 were scored as 1. Severity score in recurrent cases were 5.1±0.6 whereas 1.9±1.0 in nonrecurrent cases.

Conclusion

Granulomatous mastitis score is a tool targeted at predicting the risk of recurrences. The patients with these factors are more prone for recurrences.

Is idiopathic granulomatous mastitis a surgical disease? The jury is still out

Idiopathic granulomatous mastitis (IGM), is a rare entity of chronic inflammatory disorder of the breast of unknown etiology. Very few cases have been described so far, almost exclusively in women. Here we describe a case of IGM in a 53-year-old man presented with a right breast mass, progressively enlarging during the last 6 months. Due to the findings of clinical examination and CT-scan, the suspicion for a potentially malignant lesion was given and the decision for surgical resection was made. Microscopic analysis of the specimen showed non-caseating granulomas around mammary lobules, findings compatible with IGM. The patient is recurrence-free at 18-month follow-up. IGM is a rare benign inflammatory breast disease, usually seen in females of reproductive age. Establishing a diagnosis can be challenging for a surgeon and requires a high index of suspicion as most patients are initially misdiagnosed by their primary care physicians. Steroids and immunosuppressive drugs are considered as fundamental treatment modalities but they are correlated with increased rates of disease response and recurrence. On the contrary, surgical resection demonstrated significantly superior results compared to steroid-alone treatment in terms of recurrence and post-treatment recovery.

Risperidone Induced Granulomatous Mastitis Secondary to Hyperprolactinemia in a Non-Pregnant Woman-A Rare Case Report in a Bipolar Disorder

Idiopathic granulomatous lesion is a rare entity of the breast seen in young-middle aged women. Diagnosis and management of granulomatous lesions with known aetiology does not impose major clinical problems. However, most often these lesions are undetected or unnoticed due to lack of timely diagnosis and inappropriate management, as primarily it is idiopathic. Hyperprolactinemia have been proposed as one of the mechanisms underlying the development of granulomatous lesions of the breast. We report a case of hyperprolactinemia due to risperidone therapy for bipolar mood disorder in a woman who eventually developed granulomatous mastitis. Histologically, the diagnosis was confirmed by the presence of granulomatous lesion and by ruling out other potential causes. In this case, raised prolactin was possibly an important factor which was secondary to risperidone therapy. However, idiopathic granulomatous mastitis could not be completely ruled out.

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.

Aetiology of idiopathic granulomatous mastitis

Idiopathic granulomatous mastitis is a rare chronic inflammatory lesion of the breast that can clinically and radiographically mimic breast carcinoma. The most common clinical presentation is an unilateral, discrete breast mass, nipple retraction and even a sinus formation often associated with an inflammation of the overlying skin. The etiology of idiopathic granulomatous mastitis is still obscure. Its treatment remains controversial. The cause may be the autoimmune process, infection, a chemical reaction associated with oral contraceptive pills, or even lactation. Various factors, including hormonal imbalance, autoimmunity, unknown microbiological agents, smoking and α 1-antitrypsin deficiency have been suggested to play a role in disease aetiology. In this review, causing factors in the aetiology of idiopathic granulomatous mastitis are reviewed in detail.

[Erythema nodosum during the course of idiopathic granulomatous mastitis]

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is a benign, aseptic inflammatory disease of unknown origin, which must be distinguished from tumoral and infectious processes that affect the breast, including tuberculosis. IGM is a rare cause of erythema nodosum, but it is useful for dermatologists to be aware of this association.

PATIENTS AND METHODS

A 32-year-old nulliparous woman presented with erythema nodosum, arthralgia and fever. On examination, she had a firm and painful mass of 5cm in the right breast with retraction and axillary adenopathy. The breast lump developed gradually over the preceding 4 months. Although two biopsies showed no evidence of atypical cells, inflammatory areas and a granulomatous process were seen. Culture of breast tissue for mycobacteria was negative. A diagnostic of idiopathic granulomatous mastitis was made. Systemic corticosteroids led to a reduction in size of the mass, but relapse occurred in the contralateral breast on dose-reduction of the corticosteroids.

DISCUSSION

IGM is a rare disease of unknown aetiology. Diagnosis is based on characteristic histological features and exclusion of other granulomatous diseases. Extra-mammary signs are rare and include erythema nodosum, arthralgia and episcleritis. Management is poorly codified.