Treatments for Idiopathic Granulomatous Mastitis: Systematic Review and Meta-Analysis

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

Objective

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

Materials and Methods

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

Results

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

Conclusion

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

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.

Serum C-Reactive Protein and Interleukin-6 Levels as Biomarkers for Disease Severity and Clinical Outcomes in Patients with Idiopathic Granulomatous Mastitis

Idiopathic granulomatous mastitis (IGM) is a rare inflammatory breast disease mimicking breast cancer. Limited research has been conducted on the application of serum biomarkers. This study aims to investigate the association of serum biomarkers with disease severity in patients with IGM. From November 2011 to March 2020, medical records of patients with IGM were reviewed. Serum cytokine levels were measured in patients and healthy controls between July 2018 and March 2020. A total of 41 patients with histologically proven IGM were found. Serum interleukin (IL)-6 level was significantly higher in patients with IGM (n = 11) than healthy controls (n = 7). Serum IL-6 and C-reactive protein (CRP) levels were significantly higher in patients with severe disease than mild and moderate disease. Serum IL-6 (Spearman’s ρ = 0.855; p < 0.001) and CRP (Spearman’s ρ = 0.838; p = 0.001) levels were associated with time to resolution. A higher serum CRP level was associated with a longer time to resolution (B = 0.322; p < 0.001) in multiple linear regression analysis. Serum IL-6 and CRP levels can be used as biomarkers for the evaluation of disease severity in IGM. IL-6 may play a crucial role in the immunopathology 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.

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.

Red flags for the differential diagnosis of granulomatous mastitis: a case report

Background

Granulomatous mastitis (GM) is a rare benign chronic inflammatory breast disease. GM presents as a heterogeneous illness with variable clinical presentations, and its diagnosis is usually made by exclusion. There are no guidelines for the treatment of GM. This manuscript describes the management of a patient with GM, initially unsuccessfully treated outside our clinic under a diagnosis of mastitis. The patient’s history, physical examination, and needle biopsy flagged the patient’s findings as nonmalignant; however, imaging studies indicated a tumor. Differential diagnosis became a critical element of her care. This case report represents a valuable resource to foster more assertive clinical practice in managing patients with GM. The case coordination and its course were led by a team from an outreach clinic that provides health care services to underserved communities in the state of Michigan.

Case presentation

A 41-year-old G1P1 Hispanic female immigrant from Central America presented with a rare breast disease, granulomatous mastitis. A similar presentation occurred 5 years before pregnancy when she had an episode of pain and swelling in the left breast, which resolved spontaneously. She sought our services after being diagnosed with mastitis that was unsuccessfully treated. Physical examination revealed a nodular mass in the outer quadrants of the left breast without regional lymphadenopathy. Needle biopsy showed fibrohistiocytic and florid inflammatory reactions, with no evidence of invasive carcinoma. However, this result was inconsistent with the degree of abnormality revealed by the mammogram (BI-RADS grade 5), ultrasound, and physical examination. Full incisional biopsy revealed cystic neutrophilic GM. The surgical procedure, antibiotics, and corticosteroids resulted in a successful combination to secure the stable control of the symptoms and progression of this rare benign breast disease to date.

Conclusions

This patient’s case highlights the importance of integrated communication among front-line primary care and other health care professionals to reduce the risk of invasive procedures and avoid institutional costs. GM is a rare disease. We raised the manifold red flags in which the multiple professional chains recruited to care for this patient were concerning for advanced breast cancer. The lack of experience and evidence-based medicine contributed to the contradictory interpretation of the findings on GM's diagnosis.

Postoperative Yanghe decoction regimen improves outcomes for idiopathic granulomatous mastitis: A retrospective cohort study

The etiology of idiopathic granulomatous mastitis (IGM), a rare inflammatory breast disease, is not understood. There is no consensus regarding the treatment of IGM. The purpose of this study was to determine the efficacy of surgery combined with traditional Chinese medicine for the treatment of IGM.We retrospectively analyzed 53 patients of IGM who were treated with surgical excision at our hospital. Group A (n = 25) included patients treated with only surgery, and Group B included patients treated with surgery combined with postoperative Yanghe decoction. The clinical data were compared between the 2 groups, including demographics, clinical characteristics, and outcomes.All patients were female with a mean age of 34.6 ± 5.9 years. There were no significant differences between the groups regarding preoperative demographics or clinical characteristics. The follow-up time was comparable between the groups (13.2 ± 10.0 vs 12.0 ± 10.2 months). Patients in Group B had shorter complete remission (CR) times than patients in Group A (76.1 ± 15.2 vs 84.0 ± 12.2 days; P < .05). The CR rate was higher in Group B than in Group A (96.4% vs 76.0%; P < .05), and the recurrence rate was lower in Group B than in Group A (0% vs 16.0%; P < .05).The postoperative Yanghe decoction regimen was associated with more rapid recovery after IGM surgery. Surgical management combined with postoperative oral Yanghe decoction treatment yielded a higher CR rate and lower recurrence rate than surgery alone. The effect of traditional Chinese medicine in IGM treatment requires further study.

Multicentre, randomised, open-label, non-inferiority trial comparing the effectiveness and safety of ductal lavage versus oral corticosteroids for idiopathic granulomatous mastitis: a study protocol

INTRODUCTION

The ideal treatment for idiopathic granulomatous mastitis (IGM) remains unclear. In a prospective, single-centre, pilot study, we reported that ductal lavage treatment for non-lactational mastitis patients had a 1-year clinical complete response (cCR) rate of >90%, without any significant adverse events. Thus, in this multicentre, randomised, open-label, non-inferiority trial, we will aim to compare the effectiveness and safety of ductal lavage vs oral corticosteroids as the first-line treatment for patients with IGM.

METHODS AND ANALYSIS

The trial will be conducted at the Breast Tumor Center of Sun Yat-sen Memorial Hospital in China and at least at one participating regional centre. We plan to recruit 140 eligible IGM patients who will be randomised into the ductal lavage group or oral corticosteroid group with a 1:1 ratio. The patients in the oral corticosteroid group will receive meprednisone or prednisone for 6 months. The patients in the ductal lavage group will receive ductal lavage and breast massage, as previously reported. All the participants will be followed up at the clinic for 1 year post randomisation. The primary endpoint of this trial will be the 1-year cCR rate, and the secondary endpoints will include the time to cCR, treatment failure rate, relapse rate and protocol compliance rate. The trial was designed to determine whether ductal lavage is non-inferior to oral corticosteroids (1-year cCR rate assumed to be 90%), with a non-inferiority margin of 15%.

ETHICS AND DISSEMINATION

The ethics committee of Sun Yat-sen Memorial Hospital at Sun Yat-sen University approved the study (2018-Lun-Shen-Yan-No. 30). The results of the trial will be communicated to the participating primary care practices, published in international journals and presented at international clinical and scientific conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03724903); Pre-results.

Benign Breast Disease in Women

BACKGROUND

Most clinical breast changes in women are benign; in only 3% to 6% of cases are they due to breast cancer. How- ever, there is a lack of up-to-date, evidence-based treatment recommendations for the various benign differential diagnoses.

METHODS

Selective literature search of PubMed from 1985 to May 2019, including current national (AWMF, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften [Association of Scientific Medical Societies in Germany]) and inter- national guidelines.

RESULTS

Mastalgia and fibrocystic changes are common (around 50% of all women over the age of 30). Fibroadenomas occur in 25% of women; they are the most common benign tumors of the breast and do not require treatment. With most benign breast changes the risk of dedifferentiation is very low. However, it is important in the differential diagnosis to distinguish between such benign changes and breast cancer or changes that carry a risk of malignancy. Complex cysts, for example, carry a risk of malig- nancy of 23% to 31%, papillary lesions 16% , and radial scars 7%. Where there is doubt, histological confirmation should be sought by means of percutaneous biopsy.

CONCLUSION

Benign breast changes can be definitively distinguished from malignant lesions through the selective use of avail- able diagnostic investigations and interdisciplinary collaboration. When lesions of uncertain malignant potential are found (B3 in the biopsy classification), complete excision is indicated. Prospective studies on the early diagnosis of breast cancer in lesions carrying a risk of malignancy are desirable.

Comparison of Topical, Systemic, and Combined Therapy with Steroids on Idiopathic Granulomatous Mastitis: A Prospective Randomized Study

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is a benign disorder of the breast, for which the optimal treatment modality remains missing.

METHODS

A total of 124 patients with a histopathologically proven diagnosis of IGM were enrolled in a prospective, randomized parallel arm study. Patients were treated with topical steroids in Group T (n: 42), systemic steroids (0.8 mg/kg/day peroral) in Group S (n: 42), and combined steroids (0.4 mg/kg/day peroral + topical) in Group C (n: 40). Compliance with the therapy, response to the therapy, the duration of therapy, side effects and the recurrence rates were compared.

RESULTS

Sixteen patients did not comply with the treatment, and the highest ratio of compliance with therapy was seen in Group T (p < 0.05). Complete clinical regression (CCR) was observed in 90 (83.3%) patients. Response to the treatment (RT) was evaluated radiologically and observed in 89.8% of the patients. There was no statistically significant difference between groups regarding CCR, RT and the recurrence rate. The longest duration of therapy was observed in Group T (22 ± 9.1-week), whereas the shortest was observed in Group S (11.7 ± 5.5-week) (p < 0.001). The systemic side effects were significantly lower in Group T in comparison with Groups S and C (2.4% vs. 38.2% and 30.3%, respectively) (p < 0.001).

CONCLUSIONS

The efficiency of the treatment was similar for all groups, both clinically and radiologically. Although the duration of therapy was longer in Group T, the lack of systemic side effects increased the compliance of the patients with the therapy. Therefore, topical steroids would be among first-line treatment options of IGM.

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.

Factors associated with treatment duration and recurrence rate of complicated mastitis

BACKGROUND

The incidence of mastitis has increased, and this disease can lead to long antibiotic courses and complications. Here, we aimed to identify the factors associated with antibiotic duration and recurrence of complicated mastitis.

MATERIALS AND METHODS

This retrospective cohort study was conducted in a tertiary hospital in Taiwan. All hospitalized patients diagnosed with mastitis (ICD-9 code 611.0) from Jan. 1, 2012, to Dec. 31, 2016, were enrolled. Patient characteristics and clinical data were obtained from the medical charts. Recurrence was defined as mastitis within the first year after the discontinuation of antibiotics for at least 7 days.

RESULTS

In total, 214 females with a median age of 37 years old (IQR 33-45) were enrolled. A total of 148 patients (69.2%) underwent debridement, and 122 (57.0%) underwent biopsy. Histopathological examinations revealed granulation tissue in 44.6% (62/139) of the patients. Positive cultures were obtained in 65.9% (141/214) of the patients. Coagulase-negative staphylococci (64/141, 45.4%) was the most common pathogen, followed by Corynebacterium species (42/141, 29.8%). The median hospitalization length and antibiotic course were 7 (IQR 4-13) and 37 days (IQR 22-77), respectively. Three patients died of breast cancer during treatment. The recurrence rate was 18.5% (39/211). Younger age, corynebacterial infection, and pregnancy were associated with longer treatment durations (P < 0.001, 0.003, <0.001). Corynebacterial infection was associated with a 2.16-fold (95% CI: 1.11-4.20) increase in recurrence after adjusting for age.

CONCLUSION

Corynebacterial infection is associated with longer treatment courses and an increased recurrence rate of complicated mastitis. Therefore, specific treatments should be considered.

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

Background

Surgical resection can be performed for idiopathic granulomatous mastitis (IGM), but recurrence and tissue defects remain issues. Here we report our 6-year experience with a four-pattern surgical approach for IGM that involves the use of a random breast dermo-glandular flap (BDGF).

Methods

Sixty-eight consecutive patients with IGM were prospectively enrolled from 01/2012 and 03/2017. Based on the extent, shape, and location of the lesions, four different patterns of surgery based on BDGF were used to remove the lesion and repair the defect. Operative data (time, blood loss, and intraoperative complications), primary healing time, recurrence, and patient-reported outcomes (cosmetic outcome, and improvement in dressing change and bathing) at 2 years were evaluated.

Results

Patients' median age was 35 (range, 22-55) years. Duration of IGM was 3-22 months, with a median lesion size of 3.5 (range, 0.9-9.1) cm. The operative time was significantly longer, and blood loss was more important with the increasing lesion size (both P<0.05). No significant intraoperative complications occurred. All wounds healed by primary intention. IGM relapsed in three patients (3/68, 4.4%); they were treated successfully with a second operation. The self-evaluated cosmetic outcome was "much better" in 45 patients (66.2%), "a little better" in 18 (26.5%), and "same or worse" in five (7.3%). The self-evaluated improvement in dressing change and bathing was "improved a lot" in 51 patients (75.0%), "improved a little" in 11 (16.2%), and "not improved or getting worse" in six (8.8%).

Conclusions

The BDGF-based systematic four-pattern surgical approach is effective in the treatment of IGM. Recurrence rate is low, there are no complications, and the cosmetic results and improvement in dressing change and bathing are generally favourable.

Cystic neutrophilic granulomatous mastitis: an update

Cystic neutrophilic granulomatous mastitis (CNGM) is a rare subtype of granulomatous mastitis with a highly distinct histological pattern often associated with Corynebacterium species. CNGM is characterised by suppurative lipogranulomas that are composed of central lipid vacuoles rimmed by neutrophils and an outer cuff of epithelioid histiocytes. Some of the lipid vacuoles may contain sparse, rod-shaped, gram-positive bacilli that can be easily missed or dismissed. The surrounding mixed inflammatory infiltrate contains Langhans-type giant cells, lymphocytes and neutrophils. CNGM occurs in reproductive age women with a history of pregnancy and typically presents as a palpable mass that can be painful. CNGM has many mimickers, most significantly breast carcinoma. In many cases, CNGM has significant pathological and clinical overlap with other forms of granulomatous mastitis. Given the association with Corynebacterium species, early diagnosis of CNGM is essential in offering patients the most appropriate treatment. Prolonged antibiotic therapy specifically directed to corynebacteria is required, sometimes even beyond resolution of clinical symptoms. This comprehensive review of the existing literature on CNGM describes clinical-pathological features, microbiological findings, challenges associated with the microscopic differential diagnosis, clinical implications of this diagnosis and emerging treatment options. Morphological criteria and suggested comments to convey the degree of diagnostic certainty are also proposed for standard pathology reporting.

Different Treatments for Granulomatous Lobular Mastitis: A Systematic Review and Meta-Analysis

OBJECTIVE

Granulomatous lobular mastitis (GLM) is infrequently diagnosed. This study aimed to evaluate the efficacy and safety of managements for GLM in the nonlactation period.

METHODS

Publications were retrieved from PubMed, EMBASE, and the Cochrane library on September 10, 2018. We pooled and compared the outcome parameters and complete remission (CR) rates between different treatments using a meta-analysis.

RESULTS

Twenty-one publications including 970 patients treated with surgical excision, steroids, abscess drainage, antibiotics, and observation were included. Surgery significantly improved CR rate compared with steroids (p = 0.0003). There was no difference in the CR rate in patients treated with surgery alone or combined with steroids (p = 0.28). Surgery showed borderline significant efficacy in the CR rate compared with antibiotics (p = 0.06) and abscess drainage (p = 0.06). No difference was observed in effectiveness between observation and surgical management in patients diagnosed with early GLM and mild symptoms.

CONCLUSIONS

Although surgery was the ideal management for GLM, steroids and antibiotics might be ideal managements for GLM patients who are worried about surgical scars. Observation was an impressive alternative for patients with early GLM.

The Role of Establishing a Multidisciplinary Team for Idiopathic Granulomatous Mastitis in Improving Patient Outcomes and Spreading Awareness about Recent Disease Trends

Background

Iidiopathic granulomatous mastitis (IGM) is stereotypically described as a mysterious entity that mimics breast carcinoma imposing management challenges. In 2002, we established a multidisciplinary team to treat patients with IGM. This study aimed to evaluate the role of this team in improving patient outcomes. Also, a review of literature is provided to highlight recent disease trends. Patients and Methods. Pertinent data for 44 patients treated for IGM from 2002 to 2018 were analyzed and compared to data prior to 2002.

Results

Mean age at diagnosis was 37.9 years ± 6.4. The diagnosis of IGM was confirmed by True-cut biopsy (TCB), Frozen section (FS), and surgical biopsy in 70.5%, 25%, and 4.5% of patients, respectively. FS was used to assess the resection margins in three patients. Suspicion for malignancy was raised in one out of 39 ultrasound reports, and one out of 20 mammography reports. Wide local excision was the main treatment modality (95.5%). 19 patients (43.2%) received corticosteroids. Prior to 2002, IGM was only recognized after surgical resection with a 71% initial false impression of carcinoma. After 2002, the initial false clinical impression of carcinoma dropped to 29.5%. Recurrence rate was 31.82%. Younger age at diagnosis was significantly associated with recurrence (χ ² = 5.598; p = 0.018). Chi-square analysis showed no significant association between BMI and recurrence (χ ² = 0.776; p = 0.678).

Conclusion

The establishment of a multidisciplinary team for IGM was associated with a reduced erroneous impression of breast cancer, and a reduced false positive radiological diagnosis of breast carcinoma. FS was a useful confirmatory procedure. Our series included the first case of a diffuse papular rash as a systemic manifestation of IGM. Recent literature indicates that IGM is changing its face. IGM is being reported in all age groups, and even in males. The clinical manifestations have markedly expanded. Diagnosis by TCB has replaced blind surgical excision. More data regarding predictors of recurrence is accumulating.

The Predictive Value of the Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratio in Patients with Recurrent Idiopathic Granulomatous Mastitis

Objective

The aim of this study was to investigate the relationship between the inflammatory parameters including neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) and the prognosis of idiopathic granulomatous mastitis (IGM).

Materials and methods

In this retrospective study, a total of 41 patients with IGM who had no malignant disease or inflammatory pathologies were included between January 2010 and December 2017. The patients were divided into two groups according to presence or absence of recurrence. Subsequently, the relationship between patient characteristics, pre- and postoperative NLR and PLR levels and disease recurrence were evaluated.

Results

With a mean follow-up period of 28.4 months, 19.5% of patients were found to have recurrent IGM. Age, body mass index, patient characteristics such as oral contraceptive use, smoking status, and family history, surgical treatment and postoperative NLR, preoperative PLR, and postoperative PLR were not statistically significant between groups. However, only preoperative NLR was significantly associated with a recurrent IGM (p=0.024). Preoperative NLR predicted recurrence with a sensitivity of 62.5% and specificity of 84.8%.

Conclusion

These results demonstrated that a high level of NLR was predictive of poor outcome in patients with IGM.

Re-evaluating if observation continues to be the best management of idiopathic granulomatous mastitis

BACKGROUND

The presentation of idiopathic granulomatous mastitis can mimic breast cancer. Therefore, awareness of the condition is important for surgeons. The current series is the largest in a US population.

METHODS

Retrospective chart review of patients treated at a county, safety-net hospital in Arizona. Cases were identified from January 2006 to January 2019. Sociodemographic information, clinical history, management, and outcomes were collected.

RESULTS

There were 145 occurrences of idiopathic granulomatous mastitis among 120 women. Most of the patients (92%) were of Hispanic ethnicity and born outside (87%) of the United States. The average age was 35 years. Nearly all patients (95%) were parous, with an average of 3 pregnancies. Most (88%) presented with a palpable mass, and more than half (54%) of these masses were painful. Six patients had prolactinomas or hyperprolactinemia, 11 patients were pregnant, and 5 were postpartum. Early in the time period studied, 6 patients underwent excision of the masses. The remaining 114 underwent planned observation after biopsy confirmation of the diagnosis. Two patients were lost to follow-up, and the other 112 patients with idiopathic granulomatous mastitis resolved spontaneously. Nineteen had more than 1 episode. Average time to resolution was 5 months (range 0-20). Adjusted log-normal regression analysis found that later age of first live birth was associated with greater time to resolution (P < .01).

CONCLUSION

Idiopathic granulomatous mastitis is a self-limited, benign condition that waxes and wanes and eventually resolves without resection. After diagnosis, medications are unnecessary, and operations can be limited to drainage procedures for fluid collections.

A Proposal of a Clinically Based Classification for Idiopathic Granulomatous Mastitis

Objectives: There is no consensus regarding the surgical or immunosuppressive treatment of idiopathic granulomatous mastitis (IGM). This study aimed to introduce a clinical classification system for IGM that might facilitate its treatment and predict recurrence. Methods: We analyzed the management of 68 patients with IGM at (Princess Basma Teaching Hospital and King Abdulla University Hospital (1994-2016) to find out if distinct patterns of presentation exist according to the following parameters: presence of a painful or painless breast mass, local inflammation, abscess formation, communication to the skin, and extra-mammary manifestation. Results: We identified four distinct patterns of IGM: A: (13.23 %) A hard, painless breast mass. B: (52.94 %) A hard, painful breast mass with gross inflammation. C: (26.47 %) A breast abscess-like presentation. D: (7. 35 %) A subacute presentation with ulceration, sinus, or fistula formation. Erythema nodosum might complicate any of these patterns. Wide local excision in pattern A was curative with zero recurrence rate. The recurrence rates in patterns B and C were 22.20 % and 50.00 %. Patterns B, C, and D were treated by a combination of surgery and prednisolone. In keeping with this, recent literature is in favor of a wider use of immunosuppression especially in the presence of pus and extra-mammary findings. Conclusion: IGM could be classified into 4 distinct patterns according to the presenting signs and symptoms. These patterns correlated with treatment, recurrence rate, and the gross operative findings. This is the first step toward a classification for IGM. Multicenter and Meta-analysis studies are essential for a comprehensive prognostic classification. Treatment of IGM in any institution should be the responsibility of a multidisciplinary team.

Ductal Lavage for Patients With Nonlactational Mastitis: A Single-Arm, Proof-of-Concept Trial

BACKGROUND

Surgery, steroids, and/or observations alone have been proposed for patients with nonlactational mastitis (NLM), but most of these studies were retrospective. The optimal treatment for these patients remains unclear. This prospective, single-arm, proof-of-concept trial aimed to evaluate the feasibility and safety of ductal lavage as a novel treatment for patients with NLM.

METHODS

Eligible patients with NLM received an intraductal infusion of corticosteroids and antimicrobial agents and returned the next day for a breast massage. This cycle was repeated for 2 wk, and we followed up these patients for 1 y. Patients did not receive surgery or steroids after ductal lavage. The primary endpoint was the time to complete response (CR).

RESULTS

This trial included 32 patients with a median (range) age of 32 (20-53). Skin erythema and tenderness were the major symptoms. The median (range) visual analog score was 5 (0-9). There were 21 (65.6%), 4 (12.5%), and 7 (21.9%) patients diagnosed as idiopathic granulomatous mastitis, periductal mastitis, and unspecific NLM, respectively. During the ductal lavage, the median (range) number of cannulated ducts at first attempt was 5 (3-8). Ductal lavage significantly reduced the visual analog score and mastitis score (M-score) (P < 0.01). Within a median follow-up of 15.6 mo, 93.8% (30/32) of patients achieved CR. The median (range) time to CR was 6 (0.5-21) mo. Three patients (10.0%) relapsed. No adverse events associated with ductal lavage were observed.

CONCLUSIONS

Ductal lavage for patients with NLM is feasible and safe, and a definitive randomized controlled trial for further investigation is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02794688.

Granulomatous Mastitis: A Therapeutic and Diagnostic Challenge

Granulomatous mastitis (GM) is a rare benign inflammatory breast disease that affects mostly women of childbearing age with a history of breastfeeding. The etiopathogenesis is still unknown; however, inflammation as the result of a reaction to trauma, metabolic or hormonal processes, autoimmunity, and an infection with Corynebacterium kroppenstedtii have all been implicated. Clinical findings are pain, mass, hyperemia, and inflammation. Because the clinical presentation can mimic infectious mastitis or inflammatory carcinoma, the disease course is often protracted. The diagnosis is made by histopathology. Biopsies show a granulomatous formation in combination with a localized infiltration of multi-nucleated giant cells, epithelioid histiocytes, and plasma cells. Ultrasound, mammography, and magnetic resonance imaging are not specific; however, ultrasound and mammography should be done to exclude other pathologies. Due to the lack of data including randomized controlled studies, the management of GM is controversial. In Western industrialized countries, most authors use a therapy regimen starting with antibiotics and corticosteroids, followed by continuous steroid therapy and surgery in patients with persisting symptoms. More data are needed to define the best therapy. The role of immunotherapy has not yet been ascertained. The implementation of a registry to collect more information on this rare disease is highly recommended.

Granulomatous Lobular Mastitis: Antituberculous Treatment and Outcome in 22 Patients

Background

Granulomatous lobular mastitis (GLM) is a rare chronic inflammatory condition of the breast. The purpose of this study was to describe antituberculous treatment of GLM and the long-term follow-up outcome.

Methods

This retrospective study included 22 patients who had been histopathologically diagnosed with GLM at the Second Hospital of Shandong University from January 2011 to March 2015. Clinical characteristics, ultrasonography and mammography findings, laboratory tests, treatment regimens, follow-up information, and recurrences were recorded.

Results

All patients were female with a median age of 29 (range 23-44) years. The most common symptom was a breast mass with or without pain. Large irregular hypoechoic masses could be found in the breast ultrasounds of 13 patients. All patients received triple antituberculous therapy. During a median follow-up period of 40 months, 3 patients were lost to follow-up; of the remaining 19 patients, 18 achieved clinical complete remission and no recurrences were observed.

Conclusion

GLM is an unusual benign breast condition that mimics breast carcinoma in its clinical and imaging presentation. Antituberculous therapy seems to be an effective alternative option in the treatment of GLM.