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.

The effect of preoperative 18F-FDG PET on the surgical decision in early breast cancer: 5-Year follow-up

OBJECTIVE

The diagnosis, treatment, and management of the breast cancer (BC) require a multidisciplinary approach. In newly diagnosed BC, fluorine-18-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET) can detect extra-axillary regional nodal and distant lesions.

SUBJECTS AND METHODS

Between 2010 and 2015, this study included 101 patients with early-stage BC who were examined with ¹⁸F-FDG PET before surgery. Patients were divided into two groups: Group 1 consisted of patients with suspected ¹⁸F-FDG uptake and Group 2 with the remaining ¹⁸F-FDG-negative patients. Differences between these groups were tested using the Pearson chi-square test, Fisher's exact test, Mann Whitney-U test, independent t-test and ROC analysis. They could be followed-up after 2015 for 5 years. All patients were then rediscussed either neoadjuvant therapy or surgery in the oncology board in 2020 with changing neoadjuvant criteria and oncoplastic surgery techniques.

RESULTS

Fluorine-18-FDG PET was found to have a sensitivity of 77.8% and a specificity of 90.8% in detecting axillary lymph node metastasis. During the minimum 5-year follow-up, one patient had bone metastasis, 2 patients had a local recurrence, and 3 patients had metastatic lymph nodes in the axilla. In the re-evaluation of the same patients over 5 years, the decrease in mastectomy decision was remarkable (P-value 0.01).

CONCLUSION

We observed that we could not achieve a significant difference in 5-year metastasis/recurrence between the groups. Moreover, due to ¹⁸F-FDG-PET high false positivity, it significantly extended the time to surgery (P-value 0.01). In early-stage BC, ¹⁸F-FDG PET demonstrated better performance in axillary lymph nodes metastases detection in comparison with other diagnostic imaging methods, even if SLNB remains the gold standard technique.

Bilateral idiopathic granulomatous mastitis

OBJECTIVES

Idiopathic granulomatous mastitis (IGM) is a benign rare inflammatory pseudotumor. Bilateral involvement of IGM has been reported in a few cases. To our knowledge, this study is the largest series of bilateral cases to date. The goals of this study were to present clinical features of bilateral IGM and to evaluate the results of treatments.

MATERIALS AND METHODS

We performed a retrospective review of the idiopathic granulomatous mastitis database from 2010 to 2013. Ten female patients who met required histologic and clinical criteria of IGM in both breasts were included in study. Demographic data, clinical findings, medication history, and radiologic findings are presented.

RESULTS

The mean age at onset of the disease was 38.4 ± 8.3 years (range: 29-52 years). Nine patients had no recurrence during a mean follow-up period of 21 months (range: 11-26 months). Additionally, the median time to second breast involvement was 15.6 months.

CONCLUSION

Bilateral IGMs have a higher rate of more relapse and greater resistance to medical therapies than do unilateral IGMs. Surgical management should be avoided unless all medical treatment options have been exhausted. Nevertheless, expectant management seems a rational option for the treatment of bilateral IGM.

Radio-guided occult lesion localisation for breast lesions under computer-aided MRI guidance: the first experience and initial results

OBJECTIVE

The purpose of this study was to present an alternative technique for the pre-operative localisation of solely MRI-detected suspicious breast lesions using a computer-assisted MRI-guided radio-guided occult lesion localisation (ROLL) technique.

METHODS

Between January 2009 and June 2010, 25 females with a total of 25 suspicious breast lesions that could be detected only by MRI, and for whom breast surgery was planned, underwent the computer-assisted MRI-guided ROLL technique. A seven-channel biopsy breast array coil and computerised diagnostic workstation were used for the localisation procedure. Three-phase dynamic contrast-enhanced axial images were taken. After investigating the localisation co-ordinates with the help of intervention software on a workstation, an 18 G coaxial cannula was placed in the exact position determined. Following verification of the cannula position by additional axial scans, (99m)Tc-labelled macroalbumin aggregate and MRI contrast material were injected. Post-procedure MRI scans were used to confirm the correct localisation.

RESULTS

All the procedures were technically successful. The mean lesion size was 10.8 mm (range: 4-25 mm). The mean total magnet and the mean localisation times were 28.6 min (range: 18-46 min) and 13.1 min (range: 8-20 min), respectively. Grid and pillar methods were used for localisation in 24 procedures and 1 procedure, respectively. On histopathological examination, 6 malignant, 10 high-risk and 9 benign lesions were identified. All patients tolerated the procedure well. There were no major complications.

CONCLUSION

This is the first report documenting the application of MRI-guided ROLL. Based on our preliminary results, this technique is very efficient and seems to be a good alternative to wire localisation.

What has changed in the management of breast cancer in the past 25 years at the Istanbul University Hospital?

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Background: There have been important changes in diagnosis and treatment of the breast cancer during the last century. Diagnosing the cancer in early stages brought the new approaches such as breast conserving surgery instead of mastectomy and sentinel lymph node biopsy instead of direct axillary disection. In this study our purpose is to compare the operations which were performed in 1983 and 2008 on breast cancer patients of our clinic and to search the differences in their ages and tumor characteristics.

Methods: In each group the files of 100 patients, who were operated in 1983 and 2008, were compared with each other including the variabilities such as size of the tumor, age of the patient and operation technique.

Results: There were 100 patients in both of the groups. Six of the patients (6%), who were operated on in 1983, were found to be between the ages of 20-39 and this percentage was found to be much higher as 19% (19 patients) in 2008. In 1983, there wasn't any patient at stage 0 and the number of patients at stage 1 was 15 (15%), in 2008 the number of stage 0 patient was 9 (9%) and stage 1 patient was 25 (25%). Breast conserving surgery rate was found to be 9% in 1983 and 41% in 2008.

Conclusions: According to the data of this study, breast cancer is now being seen at younger ages when compared to 25 years ago. Currently the patients have diagnosis at earlier stages and the breast conserving surgery is much more prevalent. Earlier-stage diagnosis can be explained by widespread use of screening mamographies and increasing consciousness of the patients.

Extraction of a foreign body from the breast parenchyma using radioguided occult lesion localisation (ROLL) technique: a new approach

The radioguided occult lesion localisation (ROLL) technique is used for the excision of non-palpable breast lesions. This technique has not been described previously for the extraction of foreign bodies from the breast parenchyma. We report here a female patient who was admitted to our hospital with a foreign body in her right breast. The ROLL technique was used for the extraction of the foreign body.

CCND1 and CDKN1B polymorphisms and risk of breast cancer

BACKGROUND AND OBJECTIVES

Previous studies have shown alterations in the cell cycle regulatory proteins in breast carcinomas. However, the results of these studies remain controversial. Cyclin D1 (CCND1) and p27(KIP1) (CDKN1B) are two essential regulators of cell cycle progression. This study aimed to investigate the associations of CCND1 A870G and CDKN1B C79T polymorphisms with breast cancer risk.

PATIENTS AND METHODS

Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was used to determine the genotype and allelic frequencies of polymorphisms. Seventy-eight breast cancer patients and 84 age-matched healthy controls were included in the study.

RESULTS

Frequencies of CT genotype and T allele of CDKN1B were found to be higher in breast cancer patients than in controls (p=0.013, OR: 1.514 95% CI: 1.086-2.114.15; p=0.007, OR=1.496; 95% CI: 1.111-2.014, respectively). The frequency of AA genotype of CCND1 was decreased in hormone receptor- (estrogen and progesterone receptors) negative patients with breast cancer (p<0.049, OR=0.286; 95% CI: 0.071-1.142)

CONCLUSIONS

Even though CDKN1B polymorphism appears to be an important predictive factor for breast cancer risk and CCND1 polymorphism may be a prognostic biomarker for breast cancer, further investigations with larger study groups are needed to fully elucidate the role of CCND1 and CDKN1B polymorphisms in the development and prognosis of breast cancer.

Radioguided occult lesion localization (ROLL) for non-palpable breast cancer: a comparison between day-before and same-day protocols

BACKGROUND

Although radioguided occult lesion localization (ROLL) has become a widely accepted technique, the optimal time interval between the radioisotope injection and surgery has not yet been determined.

AIM

To delineate the effects of time from the injection of the radionuclide until surgery on the ROLL success rate in a patient population diagnosed as having non-palpable breast cancer.

METHODS

Between December 2004 and May 2009, 75 patients underwent ROLL procedure. The day-before protocol and same-day protocols included 50 and 25 breast cancer patients respectively.

RESULTS

The two study groups were comparable in terms of age, localization technique, radiological findings and the type of surgical procedures (P > 0.05). No statistically significant difference was noticed in the pathological diagnosis, cancer size and the surgical margin clearance between the two groups (P > 0.05).

CONCLUSIONS

Same-day injection of the radiotracer was not superior to the day-before injection in ROLL. The day-before protocol can be scheduled for the convenience of both patients and hospital staff.

Effects of hyperbaric oxygen and Pgg-glucan on ischemic colon anastomosis

AIM: In colorectal surgery, anastomotic failure is still a problem in ischemia. Here, we analyzed the effects of hyperbaric oxygen and beta-glucan on colon anastomoses in ischemic condition.

METHODS: Colonic resection and anastomosis in rectosigmoid region were done in forty Wistar-Albino rats of four groups of equal number. Colon mesentery was ligated to induce ischemia. The first group was the control group. The subjects of second group were treated with hyperbaric oxygen; the third group with glucan and the forth group were treated with both. At the forth day, rats were sacrificed, anastomotic segment was resected and burst pressures and hydroxyproline levels of anastomotic line were measured.

RESULTS: The burst pressure difference of second and third groups from the control group were meaningful (P < 0.01); the forth group differed significantly from the control (P < 0.001). There was no difference between the treated groups on burst pressure level (P > 0.05). The hydroxyproline levels in all treated groups were different from the control group significantly (P < 0.001). Hydroxyproline levels in the forth group were higher than those of the second and the third groups (P < 0.001). There were no significant differences between the second and the fourth groups in burst pressure and hydroxyproline levels (P > 0.05).

CONCLUSION: Hyperbaric oxygen and glucan improve healing in ischemic colon anastomoses by anti-microbic, immune stimulating properties and seem to act synergistically when combined together.

Colorectal cancer in patients younger than forty years of age

The records of the General Surgery Department of the Cerrahpasa Medical Faculty of 10 years duration (1981-1991) were studied retrospectively to determine prognostic factors in colorectal cancer patients younger than 40-year old. Fifty patients between the ages of 10-39 were identified. The family history was positive in 7 of the 50 patients. We found Hematochezia (60%), abdominal pain (64%), alterations in bowel movements (60%) among the presenting symptoms. The pathologic examination revealed no patients in Dukes Stage A, 14 patients in stage B (28%), 36 patients in stage C and D (72%). Distant metastases were present in 10%. Mucinous adenocarcinoma was found in 40% of the patients in whom an histological differentiation could be made. The 5-year survival rate was 25.7% and the 5-year disease free survival rate was 17.1% in the patients who were followed up. The mean survival was 30 months. Poor prognostic factors were Dukes Stages C and D, sex, age, mucinous/nonmucinous histology, tumour differentiation and grade. Patients presenting with one or more of the symptoms above should be carefully examined for colorectal cancer regardless of age because of the importance of delay and presentation with progressive disease on survival. Colorectal cancer is the second leading cause of cancer in the U. S. A. Although colorectal cancer is a disease of older group of patients, the incidence of colorectal cancer in younger patients is being increasingly reported.(ABSTRACT TRUNCATED AT 250 WORDS)

Intestinal perforation due to phytobezoar obstruction

Phytobezoars are rare causes of acute abdomen cases. Here we are reporting two cases which were presented with acute abdomen symptoms and later were found to be small intestinal perforation due to bezoar.