Granulomatous Mastitis: A Ten-Year Experience at a University Hospital

Evaluation of clinical profiles, imaging findings and antituberculosis treatment outcome in granulomatous mastitis: An Indian scenario

BACKGROUND

The management of choice for granulomatous mastitis (GM) has yet to be determined but few studies have demonstrated that anti-tubercular treatment (ATT) could be an effective alternative therapeutic option. Hence, the objective of the current study is to determine the clinical feature, radiological imaging findings, and histopathological examination results exhibited by GM and tuberculosis (TB)-proven GM as well as to evaluate the ATT clinical outcome in GM patients.

METHODS

The study was performed on 68 GM patients who were referred to the department of pulmonology by the breast clinic (from January 2018 to August 2021). Study populations were categorized into two groups GM and TB-proven GM patients and all were prescribed with standard ATT regimen and were continuously followed up. SPSS version 25 was employed for statistical assessment.

RESULTS

Our study showed that 6 patients from GM and 4 patients from the TB-proven GM group got relapsed. For patients who displayed partial remission, ATT treatment was started after assessing the side effects potential. 14.6% (n = 6) and 7.4% (n = 2) patients who initially demonstrated partial remission were also completely cured. ATT treatment curable rate was determined to be 90% (n = 37) and 81.5% (n = 22) for GM and TB-proven GM patients correspondingly. Therefore, the current study demonstrated nil significant differences between groups.

CONCLUSION

The current study warrants that ATT therapy could be an effective and better treatment of choice for GM patients irrespective of their clinical condition.

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.

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.

Idiopathic granulomatous mastitis: clinical, histopathological, and radiological characteristics and management approaches

Idiopathic Granulomatous Mastitis (IGM) is an infrequent, benign breast disease that primarily affects women during their childbearing years and can be mistaken for breast cancer. This study aimed to review the clinical, radiological, and histopathological findings of patients with IGM in addition to management and outcome. Retrospective cross-sectional study of biopsy-confirmed IGM at an academic medical center and a private hospital in Amman, Jordan. Fifty-four patients were included, with a mean age of 37.0 ± 9.04 years, mostly presenting with a breast lump (n = 52, 96.3%) and breast pain (n = 45 patients, 84.9%). Approximately half of the patients (51.9%) were parous, and 50% had breastfed for an average duration of 30.37 ± 22.38 months. Most of the patients had either solitary or multiple abscesses on breast ultrasound. Histopathological analysis (n = 35) showed mostly either moderate inflammation (n = 16, 45.7%) or severe inflammation (n = 14, 40%). Two-thirds of the patients underwent surgical interventions at the time of diagnosis, mostly incision and drainage (n = 16, 29%) or surgical excision (n = 7, 13%), and no mastectomies were performed. The most common medical treatment included a combination of antibiotics, corticosteroids, and methotrexate (n = 21, 38.8%). After follow-up, 31 patients remained in remission, 3 experienced relapses, and 3 had a chronic course. The use of corticosteroids was significantly associated with remission (p = 0.035). The presentation and demographics of IGM patients in Jordan were consistent with the existing literature. Prospective research is needed to explore different treatment options and disease outcomes.

What predicts the recurrence in ıdiopathic granulomatous mastitis?

INTRODUCTION

Idiopathic granulomatous mastitis (IGM) is a rarely seen chronic and benign disease of the breast. IGM usually emerges in women between 30 and 45 years of age and within the first 5 years after lactation. There is no consensus on the treatment of the disease. Steroids, immunosuppressive agents such as methotrexate and azathioprine, antibiotics, and surgical and conservative treatments can be preferred. In the present study, it was aimed to demonstrate the treatment options and follow-up data of the patients with IGM and to investigate the effective factors on recurrence if developed in the follow-up period.

MATERIALS AND METHOD

The data of 120 patients diagnosed with idiopathic granulomatous mastitis were evaluated for this cross-sectional retrospective study. The demographic, clinical, treatment, and follow-up features of the patients were obtained from the file records.

RESULTS

The median age value of the 120 female patients included in the study was 35 (24-67) years. Of the patients, 45%, 79.2%, 49.2%, and 15% had a past history of surgical intervention, steroid use, methotrexate use, and azathioprine use, respectively. Recurrent lesion developed after the treatment in 57 (47.5%) patients. The recurrence rate was 66.1% in the patients who underwent surgical intervention in the initial treatment. There was a statistically significant difference between the patients with and without recurrence regarding the presence of abscess, the presence of recurrent abscess, and having surgical intervention as the initial treatment in the past history. The rate of having surgery was statistically significantly higher compared with the administration of steroid therapy alone and the combination of steroid and immunosuppressive therapy in the initial treatment of the patients who developed recurrence. The rate of having surgery together with the administration of steroid and immunosuppressive therapy was statistically significantly higher than the administration of steroid and immunosuppressive therapies.

DISCUSSION

Our study showed that surgical intervention and the presence of abscess increased recurrence in the treatment of IGM. Key Points • This study has shown that surgical intervention and the presence of abscess increase recurrence. • A multidisciplinary approach to the treatment of IGM and management of the disease by the rheumatologists may be critical.

Is it tuberculosis mastitis or granulomatous mastitis? A thirteen-year experience at a university hospital

BACKGROUND

Granulomatous mastitis (GM) is a rare inflammatory disease of the breast. Tuberculosis mastitis (TM), one of the causes of GM, is a rare form of extrapulmonary tuberculosis. The clinical, radiological, and histopathological findings of TM and GM are similar, and sometimes it is difficult to make a distinction between these disease states. In this study, we aimed to evaluate the clinical and radiological features, diagnostic techniques, treatment modalities and treatment outcomes of the patients with GM and TM.

METHODS

The data of the patients with confirmed GM by histopathologic examination of biopsy specimens between 2007 and 2020 were retrospectively analyzed. Demographic features, main complaints, physical findings, radiological and laboratory data, treatment modalities, and treatment outcomes were recorded.

RESULTS

Sixty-eight GM patients with a mean age of 35.8 (18-63) years were evaluated. The patients had a mass lesion, pain, ulceration,and abscess in their breasts. All of the cases were female. Ultrasonographic examinations were performed on 62 cases. Abscess and/or sinus tract formation was detected in 34, heterogeneous hypoechoic mass in 15, heterogeneous parenchyma or parenchymal edema in 15, axillary lymphadenopathy in 18 and cysts in 13 patients. A total of 10 patients were lost to follow-up. Twenty-six patients underwent surgery for their breast lesions or had antibiotherapy (n = 13) or corticosteroid therapy (n = 7). Eleven (16.1%) patients were diagnosed with TM. These patients were evaluated by clinical examination, chest radiography, and tuberculin skin test. Acid-fast bacilli (AFB) staining and culture were negative in all cases. The diagnosis of TM was based on histopathological evaluation results. Eight of the 11 patients achieved complete remission with antituberculosis treatment.

DISCUSSION

The etiological diagnosis of GM must be based on a multidisciplinary approach. Tuberculosis mastitis should become a part of differential diagnosis of breast diseases in populations with high incidence of tuberculosis.

Granulomatous mastitis in a male breast: A case report and review of literature

Granulomatous mastitis (GM) is a rare disease, particularly among men. Herein, we present a case of GM diagnosed in a 63-year-old male patient who showed reduction in the tumor size during 3 months of observation.

Clinical, Histopathological, Imaging, and Treatment Perspectives of Inflammatory Granulomatous Mastitis: Review of the Literature

Inflammatory granulomatous mastitis is a benign inflammatory disease of the breast mostly presenting in puerperal women. The disease is characterized by recurrent bouts of mastitis with clinical picture of hyperemia, breast mass, and swelling of the breast with or without purulent discharge depending on the severity of the underlying inflammatory process. Although no true prevalence and incidence have been reported in the literature, there are several reported studies setting forth a predilection in specific ethnic groups and/ or geographical areas. Due to the intricate nature of the disease, quite often inflammatory granulomatous mastitis may be mistaken for malignant processes of the breast and even so, there are no pathognomonic imaging appearances to differentiate one from another. The histopathological analysis is a definite way of diagnosis. In this article, we review the imaging manifestations and clinical and histopathological findings along with current trends of available treatment options in the literature and briefly discussed our institutional perspective regarding grading of inflammatory granulomatous mastitis based on ultrasonographic appearances.

Diagnostic and Management Perspectives in Alveolar Echinococcosis: Review of Literature

Alveolar echinococcosis is a life-threatening zoonotic disease caused by Echinococcus multilocularis. The disease usually primarily involves the liver and shows tumor-like growth. Early diagnosis of alveolar echinococcosis is difficult because the disease is usually asymptomatic in the early stages. Untreated cases are fatal and result in death within 10 years of liver involvement. In the diagnosis of alveolar echinococcosis, the patient's medical history, radiological imaging findings, and serological and histopathological tests are used together. Radiological imaging methods are very important for early diagnosis and differential diagnosis of the disease. In this article, we wanted to review the diagnosis and treatment of alveolar echinococcosis and emphasize the importance of keeping it in mind, especially in cystic lesions of the liver, and the importance of early diagnosis of the disease.

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.

Post-operative Ayurvedic management of non-healing idiopathic granulomatous mastitis - A case report

Idiopathic granulomatous mastitis (IGM) is a chronic inflammatory disease of the breast which may present as painful, unilateral, discrete, breast masses with a tendency to recur. The pathogenesis is still unclear. In Ayurvedic literature, clinical features similar to IGM is seen in Stanavidradhi (breast abscess). We present the case of a 25-year old uniparous woman who had previously undergone excision biopsy for a breast lump and was diagnosed with IGM by histopathology examination. After one month, she developed pain, redness, and swelling at the operated site. She was treated for two months with corticosteroids and antibiotics, but the symptoms did not subside. After Ayurvedic treatment, the condition started to respond in a week and was completely resolved within three months. She was followed-up with medicines for three months and without medicines for another six months during which period, no recurrence was seen. The non-healing nature and high rate of recurrence of IGM necessitates prolonged treatment with steroids and antibiotics that have long-lasting adverse effects. In this context, Ayurveda may be able to offer an effective option with significantly fewer adverse effects, not only in the management of abscess and sinus, but also in prevention of recurrence.

Idiopathic granulomatous mastitis after ductoscopy: A case report

Introduction and importance

Idiopathic granulomatous mastitis (IGM) is an uncommon, benign, chronic inflammatory breast disease of unknown etiology, unpredictable duration, and unclear therapy.

Presentation of case

A 41-year-old woman presented with pathological nipple discharge for which ductoscopy was performed. Post-ductoscopy, the patient developed abscesses in her breast with histopathological confirmation of granulomatous mastitis (GM).

Clinical discussion and conclusion

IGM has an unknown etiology and atypical presentation. This is the only case described in which IGM occurred after ductoscopy. This can be related to trauma-induced GM or underlying IGM aggravated by ductoscopy.

•

Idiopathic granulomatous mastitis (IGM) has an atypical presentation.

•

Radiological findings are non-specific in diagnosing IGM.

•

GM can occur after ductoscopy. Whether this is trauma-induced GM or underlying IGM aggravated by ductoscopy remains unknown.

The therapeutic dilemma of idiopathic granulomatous mastitis

INTRODUCTION

Idiopathic granulomatous mastitis (IGM) is a rare, benign, chronic breast condition that can cause repeated abscesses or mass formation in bilateral breasts. The condition can severely impact the quality of life of affected women. This study aims to evaluate effective treatment modalities, as well as understand the demographics and clinical presentation of patients with IGM.

METHODS

An 11-year retrospective review was performed of patients diagnosed with IGM from 1 January 2008 to 31 December 2018 at a tertiary breast unit.

RESULTS

A total of 77 patients were included in the study. The median age at presentation was 36 years old. IGM presented most commonly as a breast lump (98.1%). The median number of flares was 2 (1-12). Of the 77 patients, 68.8% (53) were treated with antibiotics, 50.6% (39) with steroids, and 44.2% (34) underwent surgery, in the course of their IGM treatment. Forty-five (59.2%) of the 76 patients with IGM required a multimodal treatment approach to achieve remission. There was no significant difference in the number of flares no matter the initial treatment (P=0.411), or subsequent treatment modality (P=0.343). Smokers had 10 times greater odds of having a "high flare" of IGM compared to those who did not smoke (P=0.031, odds ratio 10.444, 95% confidence interval 1.092-99.859).

CONCLUSION

IGM is a clinical diagnosis. It is a rare, relapsing breast inflammatory condition that affects young females with no superior treatment modality. Smoking is associated with higher number of flares of IGM and should be discouraged in IGM patients.

Treatment of Granulomatous Mastitis: Is There a Role for Antibiotics?

OBJECTIVE

To perform a retrospective review of the clinical characteristics, microbiological data, and clinical outcomes in patients with granulomatous mastitis (GM) who were treated at our institution with a unique strategy of prolonged antibiotic therapy as the primary treatment modality.

MATERIALS AND METHODS

A retrospective case series was performed on patients (n = 42) with GM seen at the breast specialty clinic of our institution between the years 2004 and 2014. Patients were primarily treated with lipophilic antibiotics, and steroids and surgery were reserved for refractory cases.

RESULTS

Bacteria were identified in 34 samples from 22/42 patients (52.3%). Diphtheroids (presumptive Corynebacterium spp.) were most commonly identified, followed by Corynebacterium spp. and Propionibacterium acnes (now Cutibacterium acnes). Antibiotics were our preferred first-line medical therapy and were used in 33/36 (91.7%) patients. The mean duration of antibiotic therapy was 7.0±4.5 months. Clarithromycin was our antibiotic of choice and was the initial antibiotic used in 15 of the 33 patients (45.5%) treated with antibiotics. Eleven patients required adjunctive therapy with prednisone. The mean duration of steroid therapy was 4.3±2.5 months. Surgery for therapeutic purposes included incision and drainage in seven patients, fine needle aspiration in eight patients, and excision of the fistulous tract in one patient. No patients had large-volume excisions. The average time from the first breast clinic visit to clinical resolution was 8.0±4.6 months.

CONCLUSION

GM may be the result of a bacterial process that induces a unique form of inflammatory response. Clinicians should consider special requests to microbiology laboratories to attempt to isolate Corynebacterium spp. in the evaluation of samples sent to the laboratory for analysis. An extended course of a lipophilic antibiotic is a largely unexplored but potentially effective treatment option with low associated morbidity. More research is needed in this area.

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.

Treatment Effect of Mammary Duct Exploration Combined with Focal Resection on Granulomatous Lobular Mastitis

OBJECTIVE

This study aims to summarize the treatment of granulomatous lobular mastitis with a low recurrence rate and high satisfaction rate.

METHODS

In this study, the epidemiology and treatment effect was analyzed based on the general data and treatment effects. Patients treated for granulomatous lobular mastitis at the Dongzhimen Hospital, Beijing University of Chinese Medicine, and Beijing Contemporary Hospital from October 24, 2016, to May 8, 2019, were selected as subjects for the study.

RESULTS

The results revealed that the common features of granulomatous lobular mastitis were nipple retraction, history of induced abortion, nipple discharge, history of thyroid disease, history of lactation mastitis, and mental illness. The cure rate of the disease was 100%, the recurrence rate was 0.38%, and the patient satisfaction rate was 97.71%.

CONCLUSION

The combination of mammary duct exploration and focal resection has a positive effect on the treatment of this disease and is worthy of clinical popularization.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Severe idiopathic granulomatous mastitis treated with systemic medication; A case report

Idiopathic granulomatous mastitis is a benign chronic inflammatory breast disease and a confused treatment plan may result in worsening of the disease, unacceptable cosmetic damage for the patient and even mastectomy. We report a case of a 39-year-old Chinese woman with a two-month history of painful, solid, diabrotic, left breast lesions that measured 10 × 15 cm. Misdiagnosis had led to delayed wound healing with extensive ulcerative skin lesions. The patient was successfully treated with oral corticosteroids and bromocriptine without requirement for surgery.

Ultrasound classification-guided minimally invasive rotary cutting in granulomatous lobular mastitis

Background

To summarize the clinical experience of ultrasound-guided minimally invasive surgery for granulomatous lobular mastitis (GLM), and explore the feasibility of this technique for treating GLM.

Methods

This retrospective study reviewed the clinical features and treatment outcome of 30 patients who were diagnosed pathologically as GLM from 2016.3 to 2019.5 in the Department of Breast Surgery, Women's and Children's Hospital, Xiamen University. These patients weretreated with ultrasound-guided Mammotome minimally invasive surgery, and we tried to classified the lesion into four distinct patterns (diffuse abscess mixed type, sheet hypoechoic type, localized abscess type, localized hypoechoic mass type) according to the sonographic findings and clinical symptoms to find out if these patterns correlated with treatment and recurrence rate.

Results

After a median follow-up of 12 months on average (4–42 months), 26 cases (86.7%) were cured without acute or chronic complications such as disseminated inflammation and bleeding. Post-operative bleeding occurred in 1 case, and 3 cases (10.00%) relapsed. The ultrasound classification had 0 cases of diffuse abscess mixed type, 17 cases (56.7%) of sheet hypoechoic type, 9 cases (30%) of localized abscess type, and 4 cases (13.3%) of localized hypoechoic mass type. All 3 recurrent cases were sheet hypoechoic type, which were cured after another open surgical resection and showed no recurrence during an average follow-up of 20 months (11–40 months).

Conclusions

In treating GLM patients with minimally invasive rotary cutting, ultrasound classification helps to select suitable patients, especially those with localized abscess and localized hypoechoic mass types with low recurrence rate, which is one of the safe and effective treatment methods.

Quantitative perfusion parameters of benign inflammatory breast pathologies: A descriptive study

PURPOSE

With this study, we evaluated the perfusion magnetic resonance imaging (MRI) features of benign inflammatory breast lesions for the first time and compared their K_trans, K_ep, V_e values and contrast kinetic curves to benign masses and invasive ductal carcinoma (IDC).

MATERIALS AND METHODS

Perfusion MRIs of the benign masses (n = 42), inflammatory lesions (n = 25), and IDCs (n = 16) were evaluated retrospectively in terms of K_trans, K_ep, V_e values and contrast kinetic curves and compared by the Kruskal-Wallis, Mann-Whitney U, chi-square tests statistically. Cronbach α test was used to measure intraobserver and interobserver reliability.

RESULTS

Mean K_trans values were 0.052 for benign masses, 0.086 for inflammatory lesions and 0.101 for IDC (p < 0.001). Mean K_ep values were 0.241 for benign masses, 0.435 for inflammatory lesions and 0.530 for IDC (p < 0.001). Mean V_e values were 0.476 for benign masses, 0.318 for inflammatory lesions and 0.310 for IDC (p = 0.067). For inflammatory and IDC lesions, K_trans and K_ep values were found to be higher and V_e values were lower than benign masses (p = 0.001 for K_trans, p = 0.001 for K_ep, p = 0.045 for V_e). There were excellent or good intra-interobserver reliabilities. For the kinetic curve pattern, most of the benign lesions showed progressive (81%), inflammatory lesions progressive (64%) and IDC lesions plateau (75%) patterns (p < 0.001).

CONCLUSIONS

On T1 perfusion MRI, similar to IDC lesions, inflammatory lesions demonstrate higher K_trans and K_ep and lower V_e values than benign masses. Quantitative perfusion parameters are not helpful in differentiating them from IDC lesions.

Clinical and imaging features of idiopathic granulomatous mastitis - The diagnostic challenges and a brief review

Idiopathic granulomatous mastitis (IGM), or granulomatous lobular mastitis is a rare, benign, inflammatory condition of the breast, without an identifiable underlying etiology. The clinical and imaging diagnosis of this entity is challenging with the presentation frequently mimicking inflammatory breast carcinoma (IBC). Mammography and breast ultrasound (US) have an important role in its detection, however, biopsy is imperative for histopathological confirmation. We present three cases of biopsy proven IGM, highlighting the variability of the clinical and imaging features,brieflyreview the relevant literature and discuss the challenges associated with its diagnosis and management.

Comparison of the Outcome of Low Dose and High-Dose Corticosteroid in the Treatment of Idiopathic Granulomatous Mastitis

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory breast condition with unknown etiology. Different treatments including corticosteroids have been recommended with no universal consensus. In this study we evaluated the efficacy of low dose vs. high dose prednisolone in treatment of IGM.

METHODS

In this randomized clinical trial, 30 female patients with IGM were randomly allocated to receive low dose or high dose prednisolone. First group received 5 mg daily prednisolone, while the second group received 50 mg for three days, 25 mg for the next three days and then 12.5 mg for further three days and 5 mg daily afterwards, both for two months. Patients were evaluated 2, 3, 6 and 12 months after treatment. The success and recurrence rate was compared between groups.

RESULTS

High dose group had significantly higher rate of remission compared to low dose group (93.3% vs. 53.3%, p=0.03). One patient in high dose group and 5 patients in low dose group underwent lumpectomy due to persistent symptoms. Two other patients in low dose group received high dose treatment after three months due to no change in symptoms. Among patients with remission, recurrence was also significantly lower in high dose compared to low dose prednisolone (0% vs. 37.5%, p=0.04).

CONCLUSION

High dose prednisolone has high success rate with lower recurrence in the treatment of IGM and could reduce the need for surgery. However, further studies are necessary to confirm these findings.

Minimally invasive comprehensive treatment for granulomatous lobular mastitis

Objective

To describe a minimally invasive comprehensive treatment for granulomatous lobular mastitis (GLM) and compare its effect with the existing methods, particularly in terms of its recurrence rate and esthetic outcomes.

Methods

This retrospective study reviewed 69 GLM patients receiving the minimally invasive comprehensive treatment. Patients’ information, including age, clinical features, image characteristics, histopathological findings, mastitis history, treatment process, operative technique, recurrence, and esthetic effect, was evaluated.

Results

All patients were female with a median age of 32 (range 17–55) years. Hospital stays ranged from 2 to 34 days, with a median of 6 days. The shortest time for complete rehabilitation was 2 days and the longest time was 365 days, with a median of 30 days. After a median follow-up of 391 days (range 162–690), 7 patients (10.14%) relapsed. The average cosmetic score was 2.62 ± 0.57 points and was mainly related to the past treatment, especially the surgical history.

Conclusion

Minimally invasive comprehensive treatment is a new method for the treatment of GLM, ensuring a therapeutic effect while maintaining breast beauty.

Imaging findings and classification of the common and uncommon male breast diseases

Male breast hosts various pathological conditions just like "female breast." However, histo-anatomical diversities with female breast lead to many differences regarding the frequency and presentation of diseases, the radiologic appearance of lesions, the diagnostic algorithm, and malignity features.Radiological modalities may play an important role in evaluating male breast lesions. Although some imaging findings are non-specific, having knowledge of certain imaging characteristics and radiologic patterns is the key to reduce the number of differential diagnoses or to reach an accurate diagnosis.Male breast imaging is mostly based on physical examination and is required for the complaints of palpable mass, breast enlargement, tenderness, nipple discharge, and nipple-skin changes. The majority of the male breast lumps are benign and the most common reason is gynecomastia. Although it is difficult to exclude malignancy in some cases, gynecomastia often has distinguishable imaging features. Pseudogynecomastia is another differential diagnosis that may be confused with gynecomastia. The distinction is important for the treatment plan.Apart from gynecomastia, other male breast lesions form a highly heterogeneous group and can be classified based on "Tissue origin," "Histopathological type and behavior," and "Radiologic features" for both simplification and comprehensive understanding.This article mainly focuses on emphasizing the results of basic histo-anatomical differences of male and female breasts, classifying male breast lesions, covering the spectrum of male breast diseases, and assisting radiologists in recognizing the imaging findings, in interpreting them through a holistic approach, in making a differential diagnosis, and in being a part of proper patient management.

Breast Tuberculosis in Women: A Systematic Review

Breast tuberculosis (TB) is rarely reported and poorly described. This review aims to update the existing literature on risk factors, clinical presentations, constitutional symptoms, diagnostic procedures, and medical and surgical treatments for breast TB. In all, 1,478 cases of breast TB were collected. Previous history of TB was reported in 19% of cases. The most common clinical appearance of the lesion was breast lump (75%). The most common associated finding was axillary lymphadenitis (33%) followed by sinus or fistula (24%). The most common symptoms were pain and fever, reported in 42% and 28% of cases, respectively. The most used diagnostic method was fine-needle aspiration cytology (32%), followed by biopsy (27%), acid-fast bacteria Ziehl-Neelsen stain (26%), culture (13%), and polymerase chain reaction (2%). These tested positive in 64%, 93%, 27%, 26%, and 58% of cases, respectively. The majority (69%) of patients received a 6-month anti-TB treatment (isoniazid, rifampicin, pyrazinamide, and ethambutol). Surgery consisted of excision in 39% of cases, drainage in 23%, and mastectomy in 5%. The great majority of patients had a positive outcome. It often mimics breast cancer, which makes it difficult to diagnose. Most patients, when diagnosed in time, respond to antitubercular therapy alone.

Mycobacterium mucogenicum skin and soft tissue infection of the breast mimicking idiopathic granulomatous mastitis

We present a case of a 28-year-old woman who came to medical attention after noticing a breast mass associated with an overlying eroded plaque of the skin. A core biopsy of the breast mass was negative for malignancy but demonstrated granulomatous inflammatory changes. Acid-fast bacilli and Gomori methenamine-silver stains were negative for microorganisms. The patient was diagnosed with presumptive idiopathic granulomatous mastitis and started on oral steroids. Her symptoms progressed. Tissue culture from a repeat biopsy grew Mycobacterium mucogenicum The patient responded well to combination oral antimicrobial therapy.

Clinical study on surgical treatment of granulomatous lobular mastitis

Background

The etiology and pathogenesis of granulomatous lobular mastitis (GLM) remain unknown, with no unified evaluation criteria or standard treatments. This study aimed to assess the etiology and features of GLM, as well as the effects of surgery (lesion excision + stage I breast reconstruction; LE + BR) for GLM.

Methods

This study evaluated 178 female GLM patients retrospectively in 2006-2015. The surgery and non-surgery groups included 164 and 14 patients, respectively. All patients received conservative therapy (traditional Chinese medicine combined with regional wet compress and pus drainage). In addition, the surgery group (n=164) underwent LE + BR. Clinical data, including disease course, causes, lesion size, marital status, and treatment approaches, were assessed.

Results

Follow-up was 13-117 months. Seventy-five of the 178 patients had no overt causes (42.1%); meanwhile, 63 (35.4%) and 16 (9.0%) had congenital nipple retraction and a history of psychotropic drugs for >1 year, respectively. The surgery group showed lesions significantly shrunk (≤1 quadrant) with acute inflammation fully controlled; 8 showed recurrence, indicating a cure rate of 95.1% (156/164). In the non-surgery group, 4 cases showed relapse after 6-14 months (cure rate =71.4%; 10/14). Therefore, surgical treatment was significantly more efficient than non-surgical treatment (P=0.001). Kaplan-Meier survival curves for the two treatment types showed a significant difference in recurrence (log rank =11.84, P<0.001).

Conclusions

In GLM patients, LE + BR is safe and effective with respect to cosmetic results, recovery time, and recurrence. Successful surgery should be performed for patients whose lesions ≤1 quadrant, aim to achieve optimal GLM treatment.

Diagnostic and Interventional Radiology in Idiopathic Granulomatous Mastitis

Idiopathic granulomatous mastitis is a chronic, benign, inflammatory disease of the breast. If the radiological findings are known, patients can be referred for biopsy in the early period. The diagnosis of the disease must be based on a histologic confirmation. After diagnostic and therapeutic management, a radiological follow-up is conducted using an appropriate imaging tool. In this study, we highlight the radiologic evaluations for idiopathic granulomatous mastitis and present specific cases.

Diagnostic techniques and multidisciplinary approach in idiopathic granulomatous mastitis: a revision of the literature

Idiopathic granulomatous mastitis (IGM) is a chronic benign inflammatory disease of the breast that may mimic breast cancer. It is most common in parous young fertile women, although it can occur in nulliparous women and in men. IGM is an idiopathic disease due to the influence of some environmental factors in genetically predisposed subjects. Several pathogenic hypothesis have been proposed in the last years (autoimmune, hormonal, infective genesis). IGM presents as a painful palpable mass located in one of the two udders. The skin is usually normal but could present signs of inflammation with or without lymph nodes involvement. Ultrasonography, mammography, magnetic resonance can be diagnosed an IGM, but pathognomonic radiological signs has not yet reported in literature. Biopsy findings show granulomatous lesion centered on the breast lobule, as in granulomatous mastitis induced by tuberculosis or sarcoidosis. The aim of this review of literature is to verify the development of new advanced diagnostic techniques and multidisciplinary approach for this condition. In the last years innovative approaches have modified IGM diagnosis and therapy, avoiding surgery in most of cases, introducing a more conservative medical approach based on recent etiopathological hypothesis. (www.actabiomedica.it)

Case Report: Ductal Carcinoma in Situ Within A Granulomatous Mastitis

Granulomatous lobular mastitis is a rare chronic breast disease, firstly described by Kessler and Wolloch in 1972. In this article we present a 35-year-old patient with granulomatous lobular mastitis and in situ ductal carcinoma and discuss clinicopathological characteristics of the disease with literature data. A 35-year-old female patient admitted to the outpatient clinic with a complaint of swelling in right breast ongoing since March 2017. On the basis of physical examination and radiological examinations, antibiotic therapy was initiated considering the inflammatory breast disease and the patient was referred to our general surgery clinic because she did not benefit from treatment. On the recommendation of histopathological correlation, trucut biopsy was performed and reported as granulomatous mastitis. In the histopathological examination of the prepared sections, we found lobule-restricted, non-caseous granulomas and neoplastic epithelial cell proliferation in 4 different foci, the largest being 0.7×0.4 cm in diameter, limited to the ductal lobular system. The case was diagnosed as granulomatous lobular mastitis and in situ ductal carcinoma. This lesion, which clinically and radiologically can be confused with carcinoma, rarely coexists with breast carcinoma. Our case demonstrates the coexistence of granulomatous lobular mastitis and in situ ductal carcinoma.

Breast tuberculosis in men: A systematic review

Setting

Breast tuberculosis in male is a rarely reported and poorly described condition.

Objective

To quantify the number of breast tuberculosis in men, to describe clinical presentation and to present the diagnostic and therapeutic procedures applied.

Design

A systematic review of the literature including reports published in English, Spanish and French until December 2017.

Results

The search yielded 26 cases of male breast tuberculosis, median age 56.5 years. Most presented with an isolated breast lump (89%), associated with axillary lymphadenitis (27.8%) and skin inflammation (33.3%). The most common constitutional symptoms were pain (64.7%) and fever (35.3%). Fine-needle aspiration cytology and culture were the most common diagnostic modality (61.5%). Standard anti-tuberculosis regimen was the main treatment, alone or accompanied or preceded by incision and drainage.

Conclusions

The risk of breast tuberculosis in men appears to be low, but the condition can be difficult to diagnose and the diagnostic delays can be long. Overall prognosis is good following standard anti-tuberculosis regimen with or without incision/drainage.

The microbiology and treatment of human mastitis

Mastitis, which is generally described as an inflammation of breast tissue, is a common and debilitating disease which frequently results in the cessation of exclusive breastfeeding and affects up to 33% of lactating women. The condition is a primary cause of decreased milk production and results in organoleptic and nutritional alterations in milk quality. Recent studies employing culture-independent techniques, including metagenomic sequencing, have revealed a loss of bacterial diversity in the microbiome of mastitic milk samples compared to healthy milk samples. In those infected, the pathogens Staphylococcus aureus, Staphylococcus epidermidis and members of corynebacteria have been identified as the predominant etiological agents in acute, subacute and granulomatous mastitis, respectively. The increased incidence of antibiotic resistance in the causative species is also a key cause of concern for treatment of the disease, thus leading to the need to develop novel therapies. In this respect, probiotics and bacteriocins have revealed potential as alternative treatments.

Idiopathic Granulomatous Mastitis: Overcoming this Important Clinical Challenge

The aim of this study was to determine possible risk factors for recurrence development in patients with idiopathic granulomatous mastitis (IGM). Demographic, clinical, radiologic, and histopathologic characteristics of 34 consecutive patients with IGM were retrospectively reviewed. Also, 32 patients who were informed about recurrence status were divided into non-recurrent (n = 27) and recurrent (n = 5) groups. Both groups were compared for demographic and clinical parameters. This study included 34 female patients with IGM aged between 26 and 70 years (median: 38 years). During the follow-up period, no recurrence occurred in 27 patients whereas recurrence developed in 5 patients. No significant difference was found between the groups with respect to age, lesion size, breast-feeding, number of child, marital status, use of oral contraceptive, familial or personal tuberculosis history, PPD test, smoking, lesion side, lesion location on the breast, and treatment choice. The diagnostic tools of the IGM as follows: tru-cut (n = 18); incisional (n = 6); tru-cut + incisional (n = 5); tru-cut + excisional (n = 2); tru-cut + FNAB (n = 1); FNAB + excisional (n = 1) and FNAB (n = 1). Treatment options were as follow: antibiotics + drainage (n = 10); antibiotics + drainage + corticosteroid (n = 9); wait and watch (n = 6); corticosteroid (n = 3); antibiotics + antituberculous (n = 1); antituberculous (n = 1); antibiotics + breast conserving surgery + chemotherapy (n = 1); modified radical mastectomy + chemotherapy + radiotherapy (n = 1); and no available (n = 2). This study shows that no demographic and clinical data contributes to the development of recurrence disease. To give a strong message, this study should be supported by other high volume and prospective studies.

Imaging features and diagnosis of tuberculosis of the breast

AIM

To outline the pathophysiology, clinical presentation, imaging features, and relevant investigations of the different subtypes of breast tuberculosis (TB).

MATERIALS AND METHODS

A review was undertaken of all cases (33 in total) of breast TB presenting to Barts Health NHS Trust within a 10-year period, including patient demographics, imaging features, and route of diagnosis.

RESULTS

Thirty-three cases of proven granulomatous TB of the breast were identified (11 mastitis obliterans, 10 nodular caseous form, five sclerosing form, four disseminated disease, and three abnormal axillary lymph nodes). No cases of miliary breast TB were identified. Fine-needle aspiration cytology aided diagnosis in six patients (<20% of cases); however, the majority of patients required further investigation; namely core biopsy. Over a third of patients (12/33) had multiple clinic attendances prior to diagnosis. Mean delay in diagnosis was 3.7 months (median 0 months, IQR= 3).

CONCLUSION

Breast TB is a rare challenging diagnosis with a wide range of imaging features. Core biopsy is essential for definitive diagnosis. A multidisciplinary approach involving surgeons, radiologists, TB consultants, and microbiologists is required, coupled with a high index of clinical suspicion in order to aid timely diagnosis, and initiate prompt treatment to reduce complications.

A variety of gene polymorphisms associated with idiopathic granulomatous mastitis

Idiopathic granulomatous mastitis (IGM) is a rare and chronic inflammatory disorder. IGM mimics breast cancer regarding its clinical and radiological features. Etiology of IGM remains unclarified. Our patient was 37-year-old and 14 weeks pregnant. There was pain, redness and swelling in the right breast. The mass suggestive of malignancy was detected in sonography. Serum CA 125 and CA 15-3 levels were high. Genetic analysis was performed for the etiology. methylenetetrahydrofolate reductase (MTHFR) C 677 TT, β-fibrinogen-455 G>A, plasminogen activator inhibitor (PAI)-1 5 G/5 G, angiotensin-converting enzyme (ACE) I/D mutation was found. IGM was diagnosed by cor biopsy. An association was also reported between breast cancer and mutations in MTHFR-C 677 T, PAI-1, ACE genes. Genetic polymorphisms may involve in the development of IGM as it was seen in our case. Further studies should be conducted to better clarify this plausible association.