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

>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.

Promoting Standardization of Clinical Evidence With Severity-Guided Treatments for Idiopathic Granulomatous Mastitis: A Narrative Review

Idiopathic granulomatous mastitis (IGM) is a benign disease of the breast which causes a great deal of discomfort for patients. More comparable data and greater consensus in treatment are needed to better understand the disease and help with evidence-based clinical decision making. This narrative review aims to discuss the literature available on IGM and illustrate the need for consensus on treatment. We highlight the existing severity scores for this disease in the literature and discuss the value of severity-guided treatment. In our review, 81 studies out of 319 reviewed publications met established criteria. With the selected results from our search results, the available research on IGM etiology, risk factors, diagnosis, and treatment is summarized with an emphasis on the existing severity scores. A total of four proposed severity scores were found in our review. Consensus on the treatment of IGM must be established. There are varying severity scores on IGM severity. We suggest using an established standardized severity score to guide treatment and recommend one such score.

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.

Ultrasound-guided vacuum-assisted excision for idiopathic granulomatous mastitis at the abscess stage

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is a rare inflammatory disease of the breast with clinical features that are often confused with those of breast cancer leading to delayed diagnosis and treatment. This retrospective study aimed to evaluate the therapeutic effectiveness and cosmetic results of drainage surgery using ultrasound-guided vacuum-assisted excision (VAE) for the treatment of IGM at the abscess stage.

METHODS

The time of recovery, cases of further surgical intervention, and cosmetic results were retrospectively collected and analyzed from patients who underwent drainage with VAE or conventional drainage between October 2017 and August 2021.

RESULTS

A total of 65 patients diagnosed with IGM at the abscess stage who underwent drainage surgery with VAE or conventional drainage surgery were enrolled. Overall, 38 (58.5%) underwent conventional drainage surgery and 27 (41.5%) underwent drainage with VAE. We found that patients who underwent VAE recovered much faster than those who underwent traditional drainage surgery (30.1 vs. 48.0 days). Nine (33.3%) patients in the VAE group required further surgical intervention after drainage, whereas 33 (86.8%) patients in the control group underwent another surgery to resect residual lesions. Additionally, patients in the VAE group were more satisfied with the breast appearance, mainly due to less influence of the scars and better symmetry of their breasts.

CONCLUSION

Compared with conventional drainage surgery, drainage surgery using VAE for IGM patients at the abscess stage improved therapeutic and cosmetic outcomes. Furthermore, postoperative management of IGM is crucial.

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.

Idiopathic Granulomatous Mastitis

Idiopathic granulomatous mastitis (IGM) is a rare, benign inflammatory disorder of the breast that is often underrecognized. The exact etiology and pathophysiology are unknown, but milk stasis is felt to play a role. Classically, this condition is noninfectious, but many cases are noted to be associated with Corynebacterium species. Most patients affected are parous women with a mean age of 35, and many have breastfed within five years of diagnosis. Patients typically present with a painful mass and symptoms of inflammation, and these features can sometimes mimic breast cancer. Biopsy is needed to make a definitive diagnosis, and noncaseating granulomas are found on core biopsy. Many patients have a waxing and waning course over a period of six months to two years. Goal of treatment is to avoid surgery given poor wound healing, high risk of recurrence, and poor cosmetic outcomes. Medical treatment is preferred and includes observation, antibiotics, steroids, and immune modulators such as methotrexate. In more recent years, topical and intralesional steroids have become the treatment of choice, with similar outcomes to oral steroids.

Dermis-retained breast dermo-glandular flap: a new surgical approach for granulomatous lobular mastitis

Background

Granulomatous lobular mastitis (GLM) is characterized by nonspecific chronic inflammation concentrated in breast lobules. Surgical resection is one of the most common treatment options for GLM. On the basis of our previous use of Breast Dermo-Glandular Flap (BDGF), we designed a new surgical approach for GLM, especially for cases where the focus is close to the nipple. Here we describe this new treatment approach.

Methods

In Peking Union Medical College Hospital (PUMCH) and Beijing Dangdai Hospital during January 2020-June 2021, we enrolled all 18 GLM patients who underwent surgery with the use of Dermis-Retained BDGF. All patients were women; most of the patients were 18-50 years old (88%); and the most common clinical manifestation of GLM was breast mass (60%). Then, we collected and analyzed data about the surgery and outcomes (drainage tubes moving time, relapse, patients' shape satisfaction). We regarded GLM recurrence on the same side as relapse. If there was no complication and the patient's satisfaction was excellent or good, we rated the surgery as successful. We recorded the occurrence of all common postsurgical complications of the breast.

Results

The debridement area was 3-5.5 (4.3 ± 0.7) cm; surgery time was 78-119 (95.6 ± 11.6) min; and mean debridement time (27.8 ± 8.9 min) was shorter than the time to obtain and transplant the flap (47.5 ± 12.9 min). Blood loss was less than 139 ml. As for bacterial culture, two patients had positive results, but they had no symptoms. No surgery-related complications happened. In terms of the outcomes, all of the drainage tubes were removed in less than 5 days, and only one patient experienced relapse after 1 year of surgery during the follow-up. The patients' satisfaction with the breast shape was as follows: excellent (50%), good (22%), acceptable (22%), and poor (6%).

Conclusion

For GLM patients refractory to conservative therapy or former unsatisfactory surgical management whose lesion is in the vicinity of the nipple and larger than 3 cm, Dermis-Retained BDGF is a suitable approach to fill the after-debridement defect below the nipple-areola and achieve a relatively satisfactory cosmetic outcome.

Assertive clinical practice in managing patients with idiopathic granulomatous mastitis: Review of literature

Idiopathic granulomatous mastitis (IGM) is a benign persistent inflammatory breast entity characterized histologically by lobulo centric granulomas. Diagnosis may be difficult and involves a strong index of suspicion. There are plentiful studies are published which render the disease more frequently than expected. The strategy for imaging IGM depends on patient age, clinical manifestations, and risk factors. Patients have an excellent prognosis when they are appropriately treated. The management remains contentious, good judgment is required to ensure optimum treatment form and timing.

Risk Factors for Idiopathic Granulomatous Mastitis Recurrence after Patient-Tailored Treatment: Do We Need an Escalating Treatment Algorithm?

<b><i>Objective:</i></b> Idiopathic granulomatous mastitis (IGM) is a rare, relapsing, benign inflammatory breast disease. Due to the conflicting etiology and differential diagnosis, the effect of varied treatment regimens on high recurrence is controversial. Therefore, we aimed to report our clinical experience in determining risk factors for recurrence after patient-tailored treatment. <b><i>Methods:</i></b> This study evaluated 122 patients diagnosed with IGM according to sociodemographic characteristics, reproductive history, clinical presentation, time of diagnosis and radiological examinations, treatment management, and outcomes. The patients were classified into three groups based on curative treatment settings: medical therapy alone, surgery alone, and combined therapy. <b><i>Results:</i></b> The rates of patients receiving medical therapy alone, surgical therapy alone, and combined therapy were 23, 15.6, and 62.4%, respectively. Low vitamin B₁₂ levels, accompanying rheumatological disease, complaints-fistulae, number of complaints ≥3, presence of erythema nodosum, multicentricity, and treatment modality had a significant effect on disease recurrence (<i>p</i> &#x3c; 0.05). The effect on IGM recurrence was 2.8 times greater for the patients with lower vitamin B₁₂ levels, 4.5 times greater for those with rheumatological disease, 3.3 times greater for those with fistulae, 2.4 times greater for those presenting with ≥3 complaints, 2 times greater for the presence of multicentricity, 2.3 times greater for the presence of erythema nodosum, and 4.5 times greater for the patients receiving medical therapy alone. <b><i>Conclusion:</i></b> Describing a low-risk patient profile can be an alternative while choosing monotherapy methods. For IGM patients at high risk of recurrence, an escalating treatment system may be effective in preventing relapses.

Local Steroid Treatment: An Effective Procedure for Idiopathic Granulomatous Mastitis, Including Complicated Cases

PURPOSE

To evaluate the effectiveness of treatment with topical and intralesional steroids for idiopathic granulomatous mastitis (IGM) and to compare with surgical methods.

METHODS

Data were retrospectively collected from records. Intralesional steroid injection and topical steroid administration, hereafter referred to as local steroid treatment (LST) were applied in Group 1. Surgery (local excision, wide excision, and mastectomy) was performed in Group 2. In Group 1, changes in lesion sizes were recorded and factors complicating treatment were identified. The Numeric Pain Rating Scale was used to determine subjective pain. LST and surgery were compared with regard to: pain before and after the treatment; complication rate; recurrence rate; and treatment cost.

RESULTS

There were 38 and 48 patients in Group 1 and Group 2, respectively. In the LST group, 72 lesions were present and 70 of 72 (97%) responded completely to treatment. Pretreatment median maximum diameter was 23.50 (15.25-35.25) mm, which regressed to 16 (12-25) mm after the first session. While the pretreatment pain scores of Group 1 and Group 2 were similar (p = 0.756), there was a significant difference in the post-treatment pain scores (p < 0.001). No recurrence occurred in any patients in Group 1, while recurrence developed in 15 (31.2%) patients in Group 2 (p < 0.001).

CONCLUSION

LST is a treatment for IGM that is cheap, with high efficiency, negligible recurrence, and has good esthetic outcome. Our results suggest that LST should be the first-line treatment option for all IGM patients, including complicated cases.

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.

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.