Management of idiopathic granulomatous mastitis with observation

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.

Immune pathogenesis of idiopathic granulomatous mastitis: from etiology toward therapeutic approaches

Idiopathic granulomatous mastitis (IGM) is a noncancerous, chronic inflammatory disorder of breast with unknown causes, posing significant challenges to the quality of life due to its high refractoriness and local aggressiveness. The typical symptoms of this disease involve skin redness, a firm and tender breast mass and mastalgia; others may include swelling, fistula, abscess (often without fever), nipple retraction, and peau d'orange appearance. IGM often mimics breast abscesses or malignancies, particularly inflammatory breast cancer, and is characterized by absent standardized treatment options, inconsistent patient response and unknown mechanism. Definite diagnosis of this disease relies on core needle biopsy and histopathological examination. The prevailing etiological theory suggests that IGM is an autoimmune disease, as some patients respond well to steroid treatment. Additionally, the presence of concurrent erythema nodosum or other autoimmune conditions supports the autoimmune nature of the disease. Based on current knowledge, this review aims to elucidate the autoimmune-favored features of IGM and explore its potential etiologies. Furthermore, we discuss the immune-mediated pathogenesis of IGM using existing research and propose immunotherapeutic strategies for managing this condition.

Factors Affecting Recurrence of Idiopathic Granulomatous Mastitis: A Systematic Review

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

Efficacy of preoperative Shugan Sanjie decoction combined with mammotome-assisted minimally invasive surgery in the treatment of idiopathic granulomatous mastitis: A retrospective cohort study

The management of idiopathic granulomatous mastitis (IGM) poses a significant challenge because of its ambiguous etiology. This study aimed to investigate the efficacy of traditional Chinese medicine (TCM) combined with mammotome-assisted minimally invasive surgery (MAMIS) for the treatment of IGM. This retrospective cohort study included patients with IGM who underwent treatment at our hospital between January 2017 and June 2022. Patients treated with Shugan Sanjie decoction alone and preoperative Shugan Sanjie decoction combined with MAMIS were included in Groups A and B, respectively. We focused on the demographics, clinical characteristics, and outcomes of the patients in the 2 groups. A total of 124 female patients with an average age of 33.9 ± 3.6 years were included in the study. The demographic and clinical characteristics of patients in Groups A (n = 55) and B (n = 69) were similar (P > .05). However, there were significant differences between the 2 groups in terms of treatment duration, 1-year complete remission (CR), and recurrence. Group B showed shorter treatment time (11.7 ± 5.1 vs 15.3 ± 6.4 months, P = .001), higher 1-year CR (72.5% vs 45.5%, P = .002), and lower recurrence (7.2% vs 21.8%, P = .019) in comparison to Group A. Shugan Sanjie decoction promoted the shrinkage of breast lesions in patients with IGM. Combined with MAMIS, this treatment regimen shortened the treatment duration, accelerated the recovery process, and reduced the recurrence rate.

Challenging Management of a Breast Mass: Case Report and Literature Review

Idiopathic granulomatous mastitis (IGM) is a rare benign pathology of inflammation in the breast that commonly affects parous women of reproductive age and men although it is extremely rare. It has an unusual predilection for Hispanic women born outside of the United States, most notably in Mexico. Recently, this entity has been described more. However, the approach to management is still very controversial, and the approaches vary widely, although surgical approaches, including excision or mastectomy, have been less favored recently as a primary approach. Here, we present a case of a young female of reproductive age who presented initially with a suspicious breast lump diagnosed initially in the breast clinic as IGM and was referred to the rheumatology clinic for management with medical therapy.

Treatment and Management Experience of Idiopathic Granulomatous Mastitis in a Low-income Country

OBJECTIVE

 Reporting our experience of the management and treatment of Idiopathic granulomatous mastitis (IGM) in a low-income country by describing patients characteristics and therapy with emphasis on conservative surgical excision and postoperative care as the cornerstone of treatment.

METHODS

 A retrospective cohort of women with histopathological diagnosis of IGM from 2014 to 2018 at Instituto Nacional Materno Perinatal in Lima, Peru. Patients' characteristics, clinical presentation, treatment, management, postoperative care, and follow-up were analyzed.

RESULTS

 Thirty-eight patients with histopathological diagnosis of IGM were identified. Their average age was 35.9 years and 23 (60.5%) reported previous use of hormonal contraceptives. Nine (23.7%) patients had chronic mastitis with previous treatment. The time from the onset of symptoms to the first clinic consult was 5.1 months on average. Twenty-one (55.3%) patients had the lesion in the right breast, with a mean size of 6.9 cm. Conservative surgical excision was performed in all patients. Additionally, 86.8% required corticosteroids and 78.9% were treated with antibiotics. Complete remission was obtained at 141 days on average (range 44 to 292 days). Six (15.8%) women reported ipsilateral recurrence and 5 (13.2%), contralateral. The latency time was 25.5 months on average.

CONCLUSION

 The conservative surgical treatment demonstrated and close follow-up made for a high cure rate, but with recurrence similar to that reported in the literature. Use of gloves is an alternative to manage post operative wounds in a low-income country. The most frequent adverse effect was breast surgical scar.

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.

Idiopathic granulomatous mastitis and cystic neutrophilic granulomatous mastitis: two sides of the same coin or distinct entities?

Idiopathic granulomatous mastitis (IGM) is a benign mimic of breast carcinomas. It is defined histologically by the presence of granulomas and inflammation. The closely related cystic neutrophilic granulomatous mastitis (CNGM) shows lipogranulomas, with a reported association with corynebacteria. A large cohort of IGM was reviewed to compare clinical, microbiological and histological features between non-CNGM IGM and CNGM. Cases of IGM were reviewed for histological parameters including the presence of lipogranulomas and composition of inflammatory cells. Clinical data were obtained through hospital records. The cohort included 79 cases, including 51 non-CNGM IGM and 28 CNGM. Comparing non-CNGM IGM and CNGM, there were no differences in clinical or demographical data, other than a younger age of presentation (36.2 vs 41.5 years, p=0.012) for CNGM. Most IGM resolved within the follow-up period (n=57/64, 89.1%), with similar outcomes regardless of treatment (p>0.05). In CNGM, there were more infiltrates of neutrophils (p=0.001), histiocytes (p=0.047), and multinucleated giant cells (p=0.006), but less lymphocytes (p=0.008). Corynebacteria was cultured in two (25%) cases of CNGM, and one non-CNGM IGM (14.3%). Gram-positive bacilli were identified in two cases of CNGM. 'Early' lipogranulomas were observed closely associated to inflamed ducts in three cases of CNGM. Apart from age, there was no distinct clinical or microbiological feature for CNGM. These findings do not support CNGM as a distinct entity. Rather, CNGM-pattern may represent a continuum of IGM, possibly age-related and attributable to ductal inflammation and cystic changes in the breast parenchyma.

Demographic and Socioeconomic Risk Factors for Granulomatous Mastitis in the United States: A Case-Control Study

OBJECTIVE

Granulomatous mastitis (GM) is a benign breast disease that can have an extended clinical course impacting quality of life and causing breast disfigurement. Granulomatous mastitis has been studied throughout the world; however, less is known about GM patients in the United States. We aim to identify demographic and socioeconomic factors associated with GM in the United States.

METHODS

An IRB-approved retrospective case-control study was performed of 92 patients with biopsy-proven GM at two institutions in Los Angeles, California: a safety-net hospital and an academic institution. Age-matched controls were selected from patients presenting for diagnostic breast imaging. Demographic and socioeconomic characteristics were collected. Data were analyzed using univariable test for odds ratios (ORs) with 95% confidence intervals (CIs) and multivariable conditional logistic regression.

RESULTS

Patients with GM were more likely to prefer Spanish language (OR 6.20, 95% CI: 2.71%-14.18%), identify as Hispanic/Latina (OR 5.18, 95% CI: 2.38%-11.30%), and be born in Mexico (OR 3.85, 95% CI: 1.23%-12.02%). Cases were more likely to have no primary care provider (OR 3.76, 95% CI: 1.97%-7.14%) and use California Medicaid for undocumented adults (OR 3.65, 95% CI: 1.89%-7.08%). In the multivariable analysis, participants who preferred Spanish language had four times higher odds of GM versus those who preferred English language (OR 4.32, 95% CI: 1.38%-13.54%).

CONCLUSION

Patients with GM may have barriers to health care access, such as preferring Spanish language, being an undocumented immigrant, and not having a primary care provider. Given these health care disparities, further research is needed to identify risk factors, etiologies, and treatments for this subset of GM patients.

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.

Idiopathic Granulomatous Mastitis: Six years of experience and the current evidence in literature

Objectives

This study aimed to retrospectively describe the clinicopathological pattern and management experience of idiopathic granulomatous mastitis in women receiving care at the Royal Hospital, a tertiary care centre in Oman. The study then compared the researchers' experience with the current literature trends.

Methods

The data of patients from January 2012 to December 2017 were reviewed retrospectively, after receiving ethical approval from the Centre of Studies and Research.

Results

This retrospective study included 64 patients were confirmed to have idiopathic granulomatous mastitis. All patients were in the premenopausal phase, with only one being nulliparous. Mastitis was the most common clinical diagnosis; furthermore, half of the patients had a palpable mass. Most patients had received antibiotics during the span of their treatment. Drainage procedure was done in 73% of the patients, whereas excisional procedure was done for 38.7%. Only 52.4% of patients were able to achieve complete clinical resolution within six months of follow-up.

Conclusion

There is no standardised management algorithm due to the paucity of high-level evidence comparing different modalities. However, steroids, methotrexate and surgery are all considered to be effective and acceptable treatments. Moreover, current literature tends towards multimodality treatments planned tailored case-to-case based on the clinical context and patients' preference.

Corynebacterium kroppenstedtii breast abscesses in context, a retrospective cohort study

Corynebacterium kroppenstedtii breast abscesses and granulomatous mastitis have gained increased recognition in the 20 years since their association was first described. No studies to date have described this organism in the context of all breast abscess pathogens. We retrospectively reviewed 160 community-acquired breast abscess samples from 135 patients in a 3 year period, describing the organisms isolated along with risk factors, site of infection and outcomes. We compared patient subgroups with acute and chronic abscesses, the latter defined as having a requirement for repeat aspiration more than 1 month apart. The prevalence of C. kroppenstedtii breast abscesses was 8 % in all patients (11/135), rising to 32 % in chronic abscesses (10/31), but only 1 % in acute abscesses (1/104; P<0.01). Only 10 % (1/10) of patients with C. kroppenstedtii chronic abscesses were smokers, whereas 75 % of patients (15/20) with non-C. kroppenstedtii chronic abscesses were smokers (P=0.01). C. kroppenstedtii should be considered in recurrent and prolonged infections, especially in non-smokers, and diagnostic methods altered accordingly. Identifying C. kroppenstedtii provides diagnostic clarity and alters management with recommendations for longer courses of treatment using non-beta-lactam antibiotics.

Characteristics and Management of Granulomatous Lobular Mastitis Associated with Antipsychotics-Induced Hyperprolactinemia

Background: Granulomatous lobular mastitis (GM) is a rare inflammatory breast disease. Reports focusing on GM caused by antipsychotic-induced hyperprolactinemia (HPRL) are very rare. Aim: To report a study of GM associated with antipsychotic-induced HPRL and discuss the mechanism and management. Materials and Methods: A retrospective review of patients with GM and psychiatric disorders were carried out. The clinical characteristics, management and outcome were collected and analyzed. The relationship between antipsychotics and GM was evaluated using the Naranjo Adverse Drug Reaction Probability Scale (Naranjo scale). Results: Nineteen female GM patients with psychiatric diseases, aged 21-39 years, who had received antipsychotics for 0.5-10.2 years were included. Most patients took multiple antipsychotics, and 10 (52.6%) took risperidone-containing regimens. Increased prolactin (PRL) was detected in all patients (range 35.15-200 ng/mL). The scores of Naranjo scale were 7-8, indicated the antipsychotics probably induced GM. All patients received systemic therapy, and were prescribed bromocriptine. Seven patients (36.8%) decreased the dose of antipsychotics, six (31.6%) switched antipsychotics, three (15.8%) continued the primary antipsychotics, and three (15.8%) discontinued antipsychotics. In addition, 14 patients (73.7%) received corticosteroid, 4 (21.1%) received antimycobacterials. PRL decreased to normal in 1 month. Seven patients (36.8%) received excisional surgery. After 12 months' follow-up (range 9-56 months), only three patients (15.8%) had a recurrence. Conclusion: Long-term use of antipsychotics may increase PRL levels, and lead to GM. It is vital to assess PRL level and reduce PRL to normal in patients with GM.

Comparison of the Efficacy of Systemic Versus Local Steroid Treatment in Idiopathic Granulomatous Mastitis: A Cohort Study

INTRODUCTION

Steroid therapy is known to be effective against granulomatous mastitis. We aimed to compare the efficacy of local versus systemic steroid administration in patients with idiopathic granulomatous mastitis.

MATERIALS AND METHODS

This prospective cohort study included 58 patients who had either local (n = 42) or systemic (n = 16) treatment due to granulomatous mastitis between 2015 and 2019. Recurrence rates were determined as per ultrasound and magnetic resonance imaging examinations and the rate of side effects was evaluated as per patient complaints and physical examinations at the end of a 2-year follow-up period.

RESULTS

Median doses of 140 mg and 3810 mg were administered to the local and systemic group, respectively. Six (14.3%) patients in the local treatment group and 13 (81.3%) in the systemic treatment group had steroid-related side effects. The local treatment group had significantly fewer side effects than the systemic treatment group (P < 0.001). The recurrence rates were similar in both groups (P > 0.05).

CONCLUSIONS

Local steroid injection was as effective as systemic steroid therapy. Compared to systemic therapy, local steroid administration can be considered as a new therapeutic protocol with a lower dose and side effect rate.

Idiopathic granulomatous mastitis and steroid use during the pandemic of COVID-19

BACKGROUND

Steroid therapy is an immunosuppressive treatment and may have possible side effects in a pandemic period. However, the number of studies on the use corticosteroids for the treatment of idiopathic Granulomatous Mastitis (IGM) especially during the pandemic is almost negligible.

METHODS

The data of patients with the diagnosis of IGM between January-December 2020 in the General Surgery Clinic were retrospectively analyzed. The patients were explained in detail that steroid therapy is an immunosuppressive treatment and it may have possible side effects. Prednisolone 0.5-1 mg/kg/day was given as steroid therapy. The treatment was planned for 4-6 months according to the severity of the symptoms and was completed by reducing it to a total dose of 10 mg/month.

RESULTS

Eleven patients were included in the study. Five patients had completed steroid treatment and continued their follow-up. In our study, a total of six patients were receiving steroid therapy.

CONCLUSIONS

There is no consensus yet on the use of the steroid in the COVID-19 pandemic. Low doses Corticosteroids (<1 mg/kg/day) don't have an effect on increase mortality in patients with severe COVID-19. We can think that low-dose corticosteroids used by many centers in IGM treatment do not have a negative effect on mortality.

You'll see it when you know it: granulomatous mastitis

Granulomatous mastitis (GM) is an under-recognized and under-diagnosed disease. Patients with GM often present to the emergency room with a painful breast mass, nipple retraction, and skin changes. This pictorial essay will review the clinical presentation and imaging appearance of GM, BI-RADS reporting parameters, differential diagnoses, and diagnostic challenges posed by this disease. Early and accurate diagnosis is essential, as misdiagnosis can result in repeated core biopsies, leading to fistulae and sinus tract formation. A classic history and typical sonographic appearance allow the emergency radiologist to confidently make this diagnosis.

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.

Clinical therapeutic evaluation of vacuum sealing drainage and precise ultrasound-guided debridement in the treatment of non-lactational mastitis

The aim of the present study was to compare the efficacy of vacuum sealing drainage (VSD) and precise ultrasound-guided debridement in the treatment of non-lactational mastitis and to determine the optimal surgical treatment. A set of 60 cases diagnosed with non-lactational mastitis who had received surgical treatment at the Department of Thoracic and Breast Surgery of Xiamen Hospital of Traditional Chinese Medicine (Xiamen, China) between July 2017 and June 2019 were included. According to the surgical method, 30 patients were assigned to the VSD group and 30 patients were assigned to the precise ultrasound-guided debridement group. The clinicopathological data of the two groups were compared. The overall rates of recurrence and new incidence were 6.8 and 8.5%, respectively. The mean total disease course was 5.3 months and all of the patients were cured after treatment. Except for the hospitalization time and postoperative pain scores, the clinicopathological data between the two groups were similar. The hospitalization time in the VSD group was significantly longer than that in the precise ultrasound-guided debridement group. Pain scores on the first and third days after the operation in the precise ultrasound-guided debridement group were significantly higher than those in the VSD group (P=0.008 and 0.001, respectively). In conclusion, the efficacies of VSD and precise ultrasound-guided debridement for the treatment of non-lactational mastitis were generally both satisfactory without significant differences. Of note, the former is suitable for patients with inverted nipples and obvious skin ulcerations, while the latter is mainly suitable for patients with abscesses, small surgical incisions and those who require short hospital stays.

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

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

Management of idiopathic granulomatous mastitis in lactation: case report and review of the literature

Background

Idiopathic Granulomatous Mastitis (IGM) is a benign chronic inflammatory breast condition that mimics two common breast disorders: breast carcinoma and breast abscess. It can form breast masses, fistulae, and fluid collections, resulting in breast disfigurement with retraction and nipple areolar complex (NAC) inversion. IGM most often presents in women of childbearing age within a few years of pregnancy, and can significantly impact lactation. Despite the prevalence of this disease, no current literature describes an approach to managing IGM during breastfeeding.

Case presentation

A 28-year-old G3P2 patient of Native American origin presented to her obstetrician at 7 months pregnant with worsening left breast swelling and redness. She underwent a mammogram, ultrasound and core needle biopsy that confirmed the diagnosis of Idiopathic Granulomatous Mastitis. During the postpartum period, she underwent intralesional triamcinolone injections of her left breast. Due to the contraindication of breastfeeding after local steroid injection, the patient stopped breastfeeding from the affected breast and continued breastfeeding unilaterally.

Conclusions

Idiopathic Granulomatous Mastitis is a challenging chronic inflammatory breast disease that affects women primarily in the reproductive years, with a higher incidence in patients of Hispanic, Native American, Middle Eastern, and African descent. Treatment of IGM during pregnancy and lactation has thus far not been addressed. We review the literature on the treatment of IGM in the non-lactating population, and propose considerations for treating breastfeeding women affected by this disease. Traditional treatment has included systemic immunosuppression and surgery, but newer literature demonstrates that intralesional injection of steroid can provide significant symptomatic relief to patients. A diagnosis of IGM does not preclude breastfeeding, though patients may experience challenges with milk production and latch on the affected breast. Individualized care should be provided, with considerations given to the following: side effects of systemic steroids, the need to wean a breast being treated with intralesional steroids, and augmentation of milk production on the unaffected breast to promote continued breastfeeding.

Granulomatous mastitis, erythema nodosum and arthritis syndrome: case-based review

Granulomatous mastitis (GM) is a rare form of inflammatory breast condition associated with unilateral or bilateral breast pain, swelling and mass formation. Although the disease pathogenesis remains unknown, several reports have associated GM with manifestations such as erythema nodosum and occasionally with arthritis, suggesting that GM might have an autoimmune disease component. We aim to describe two cases of coexistence of GM, erythema nodosum, and arthritis. We also conducted a literature review to comprehensively assess and describe the characteristics of patients with GM, erythema nodosum, and arthritis, and identify effective treatment options. A literature review was conducted using PubMed and EMBASE, and 14 case reports/series were retrieved, with a total number of 29 patients. All patients are women and unilateral breast involvement was evident in the majority of patients. Nine patients (31%) presented with arthritis, 6 patients (20.7%) had a fever, and 6 patients (20.7%) developed the symptoms during pregnancy. All patients had normal chest radiograph and tissue cultures were negative. In most of the cases (n = 25, 86.2%), symptom improvement was observed with glucocorticoids and four patients (13.8%) underwent surgical treatment for the GM. Given the clinical characteristics of patients with GM, with erythema nodosum, with or without arthritis, and the positive response to glucocorticoids, we propose that the described phenotype represents an underrecognized systemic autoimmune disease that could be designated by the acronym "GMENA" (granulomatous mastitis, erythema nodosum, arthritis) syndrome. Further studies are needed to elucidate the pathogenesis of the syndrome.

What are the new findings with regard to the mysterious disease idiopathic granulomatous mastitis?

PURPOSE

To review the demographic and clinical features and the success rates of treatment approaches for idiopathic granulomatous mastitis (IGM).

METHODS

A total of 134 patients diagnosed with IGM pathologically and treated by a single breast surgeon were retrospectively analyzed.

RESULTS

The time between the occurrence of symptoms and the last delivery was < 24 months in 25 (23.1%), 24-48 months in 51 (38.1%), and > 48 months in 52 (38.8%). The difference was statistically significant (p = 0.002). Although there was no significant difference, seasonal fluctuations were noticed, with the incidence being slightly higher during late spring and summer. Bilateral disease was present in 10 (7.5%) patients. Seven patients (5.2%) had erythema nodosum. The treatment approaches were conservative in 42, surgical procedures in 48, steroid treatment in 18, and surgical procedure + steroid treatment in 24. The median recovery time with conservative approaches was lower than that with surgical procedure + steroid treatment (p < 0.0001). Recurrence developed in 10 patients (7.7%).

CONCLUSION

Clinical differences were detected among the patients with IGM, and classification of patients by severity is needed to plan the optimal treatment approach. Seasonal fluctuations suggest the possibility of an immunological disease rather than a surgical disease.

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.

Mastitis, Breast Abscess, and Granulomatous Mastitis

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

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.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Risk of breast cancer in women with non-lactational mastitis

Little is known regarding the association of non-lactational mastitis women with breast cancer risk. This population-based cohort study examined the breast cancer risk in women with non-lactational mastitis. We identified 3,091 women with non-lactational mastitis between 2000 and 2011 using the Taiwan National Health Insurance Research Database. We performed 1:4 propensity score matching by age, socioeconomic status and comorbidities and identified 12,364 women without non-lactational mastitis. The mean age of women with non-lactational mastitis was 37.9 years; these women had a higher breast cancer risk than the comparison group (adjusted hazard ratio = 1.94, 95% confidence interval: 1.30–2.90). The incidence rates of breast cancer in women with non-lactational mastitis and the comparison group were 14.79 and 7.57 per 10,000 person-years, respectively. Furthermore, non-lactational mastitis was a risk factor for breast cancer in women aged <50 years, women with lower socioeconomic status and women with hormonal medication (p < 0.05). Women who had more episodes of non-lactational mastitis had a higher risk of developing a breast cancer. Thus, the risk of breast cancer in women with non-lactational mastitis is significantly higher than those without non-lactational mastitis.

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.

Idiopathic granulomatous mastitis: Looking for the most effective therapy with the least side effects according to the severity of the disease in 374 patients in Iran

The goal of this study is to compare the response rate and the recurrence rate of available therapeutic modalities in the treatment of Idiopathic Granulomatous Mastitis (IGM). 374 patients with pathologically confirmed IGM, were included. They were subdivided into three levels of severity. Close observation had the best response rate with the lowest recurrence rate in mild to moderate cases. Severe cases were mostly treated by prednisolone or underwent surgery. The outcome of prednisolone use in severe cases was comparable to NSAIDs. Overall 9% were resistant to treatment and surgical intervention is still an option among them.

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.

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)

Idiopathic granulomatous mastitis: a 10-year study from a multicentre clinical database

Idiopathic granulomatous mastitis (IGM) is an uncommon, chronic inflammatory breast disease with elusive aetiology, simulating malignancy clinically and radiologically. Here we present our 10-year review on a region-wide multicentre IGM database. A retrospective study was performed on a prospectively maintained database from three University affiliated hospitals in Hong Kong and Shenzhen, China. All patients with biopsy proven IGM were included while patients with positive culture of Mycobacterium tuberculosis were excluded. Disease recurrence rate and its prognosticators were evaluated. A total of 102 patients were included between January 2007 and December 2017. Median age was 33 years (range 20-54). Most patients presented with painful inflammatory mass (n = 57); median size at presentation was 37 mm (6-92 mm). Sixty-three patients had bacterial culture performed on the pus sample: eight patients had Corynebacterium kroppenstedtii while four had Corynebacterium species not otherwise specified. Seventy-seven (75.5%) patients received conservative treatment with oral corticosteroid (±antibiotics) and drainage only, while 25 (24.5%) patients received breast lump excision after initial medical treatment. Twelve (11.8%) patients developed recurrence after a median follow-up interval of 14 months (4-51 months). Univariate analysis revealed that abscess on presentation, history of smoking, and presence of C. kroppenstedtii were significant prognosticators for recurrence. Subsequent multivariate analysis with logistic regression revealed cigarette smoking and isolation of C. kroppenstedtii as independent risk factors for disease recurrence (p < 0.05). In conclusion, IGM is uncommon with a recurrence rate of 12%, especially in patients with history of smoking and isolation of C. kroppenstedtii.

Cystic neutrophilic granulomatous mastitis: A clinicopathologic study of a distinct entity with supporting evidence of a role for Corynebacterium-targeted therapy

Cystic neutrophilic granulomatous mastitis (CNGM) is a distinct histopathologic entity characterized by neutrophilic and granulomatous inflammation surrounding clear cystic spaces. Rare gram-positive bacilli are sometimes identified within these cystic spaces. Studies in the literature have identified these gram-positive bacilli to be Corynebacterium species. We describe the clinicopathologic features of 7 cases of CNGM, including a case with evidence of Corynebacterium amycolatum. Patients were young to middle aged parous women ranging in age from 28 to 53 years (median age: 41 years). Gram-positive bacilli were identified in 4 cases, all within cystic spaces. Microbial culture from a 41-year old Hispanic woman grew Corynebacterium species on multiple occasions and Corynebacterium amycolatum was identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) on two separate occasions. Antibiotic susceptibility testing performed both times showed resistance to multiple antibiotics and susceptibility to vancomycin. Follow-up of all patients (range 3-12 months, median 6 months) showed a widely variable clinical course and varying response to a variety of treatment modalities. Five of the seven CNGM patients were parous, reproductive-aged Hispanic women who were born outside of the United States. Our findings further support the association of CNGM with corynebacteria and gram-positive bacilli. Furthermore, this study shows that Corynebacterium amycolatum, a nonlipophilic and multidrug-resistant corynebacterium can be associated with CNGM, hence the need for targeted antibiotic therapy. We propose identifying corynebacteria to the species level and performing antibiotic susceptibility testing in patients with CNGM because of the varied susceptibility testing profile that has been reported among different species of corynebacteria.

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.

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

OBJECTIVES

Idiopathic granulomatous mastitis (IGM) is a benign breast disease with no ideal treatment regimen so far. This study aimed to evaluate the complete remission/resolution (CR) rate and recurrence rate of different treatment options.

METHODS

We systematically searched and identified eligible studies from January 1, 2010, to December 31, 2015, in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Medline databases. We included original studies reporting the CR and/or recurrence rate of each treatment used. The pooled incidence and 95% confidence interval (95% CI) for CR and recurrence rate were calculated using Stata 13.0.

RESULTS

Fifteen eligible studies were included in our study. Six, nine, and five studies with 138, 358, and 106 patients were analyzed for surgical managements, oral steroids, and oral steroids+surgical managements, respectively. The pooled estimates for CR rate of them were 90.6% (95% CI 83.8%, 95.7%), 71.8% (95% CI 67.1%, 76.3%), and 94.5% (95% CI 88.9%, 98.3%). The pooled estimates for recurrence rate were 6.8% (95% CI 3.3%, 11.5%), 20.9% (95% CI 9.2%, 16.1%), and 4.0% (95% CI 1.5%, 8.4%), respectively. Other interventions analyzed were topical steroids, observation, oral steroids+MTX, and steroids+prolactin lowering agent, with varied pooled estimates for CR and recurrence rate.

CONCLUSION

Surgical managements had high CR rate with relatively low recurrence rate, with or without steroids. Thus, it was suitable for patients requiring rapid remission. However, for patients with concerns about surgical scarring, oral steroids could be an acceptable option. Further investigations are still needed to better understand the managements of IGM.

Benign Breast Diseases: Evaluation and Management

Benign breast disease is a spectrum of common disorders. The majority of patients with a clinical breast lesion will have benign process. Management involves symptom control when present, pathologic-based and imaging-based evaluation to distinguish from a malignant process, and counseling for patients that have an increased breast cancer risk due to the benign disorder.

An Unusual Cause of Oligoarthritis and Erythema Nodosum: Idiopathic Granulomatous Mastitis

Idiopathic granulomatous mastitis (IGM) is an unusual benign inflammatory disease of breast. Breast cancer mimics IGM both radiologically and clinically. However, IGM is a benign disease and awareness of such an entity prevents unnecessary surgical procedures. Although its etiology is unknown, it may be an autoimmune disease. There are few patients reported in the literature presenting with reactive arthritis and/or erythema nodosum accompanying IGM of breast. Granulomatous mastitis should be considered as a possible underlying cause of arthritis and erythema nodosum. In this article, we report this interesting association of IGM as an underlying cause of arthritis and generalized erythema nodosum in a 32-year-old female patient. Comprehensive examination for granulomatous mastitis showed no apparent underlying cause. Indomethacin was beneficial in treatment of arthritis and erythema nodosum. Resistant IGM was responsive to colchicine treatment. Clinical management and therapeutic approach have been discussed in detail.

Follow-up of granulomatous mastitis with monitoring versus surgery

BACKGROUND

IGM (Idiopathic Granulomatous Mastitis) is a rare, chronic, non-malignant and non-life-threatening breast disease. Clinically and radiologically, it has similar characteristics with other granulomatous diseases and breast carcinomas.

METHODS

The patients whom diagnosed IGM according to pathology report were retrospectively evaluated between November 2014 and January 2016. The demographic properties, complaints during admission, diagnosis and treatment methods and clinical results were obtained via investigation of the patient files. The patients were called for follow-up and discussion.

RESULTS

The patients whom diagnosed IGM were retrospectively evaluated and total number of patients were 19. The average following period was 11 months (4-13 months). Fourteen patients were in the reproductive period, five patients were in the postmenopausal period. Ultrasound imaging was performed on all patients, mammography was done on 6 patients over 40 years of age. The patients were not imaged by magnetic resonance imaging (MRI). Sixteen patients had IGM in a single breast, only three patient have an IGM history in bilateral breast, one or three years ago. Core biopsy was performed on all patients. One patient with bilateral IGM diagnosis performed a drainage and incisional biopsy due to a twice developing abscess clinic and recurrence. One patient had final diagnosis coexistence IGM and ductal carcinoma.

CONCLUSIONS

Patients who followed-up by observation should be explained that IGM is a chronic disease and that it may recur in certain periods. Clinical, radiological and pathological examinations should be performed together for breast cancer developing due to the chronical progresses of IGM or concurrent breast cancer.

Clinical Significance of Commensal Gram-Positive Rods Routinely Isolated from Patient Samples

Commensal bacteria from the skin and mucosal surfaces are routinely isolated from patient samples and considered contaminants. The majority of these isolates are catalase-positive Gram-positive rods from multiple genera routinely classified as diphtheroids. These organisms can be seen upon Gram staining of clinical specimens or can be isolated as the predominant or pure species in culture, raising a priori suspicion of a possible involvement in infection. With the development and adoption of matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS), suspicious isolates are now routinely identified to the species level. In this study, we performed a retrospective data review (2012 to 2015) and utilized site-specific laboratory criteria and chart reviews to identify species within the diphtheroid classification representative of true infection versus contamination. Our data set included 762 isolates from 13 genera constituting 41 bacterial species. Only 18% represented true infection, and 82% were deemed contaminants. Clinically significant isolates were identified in anaerobic wounds (18%), aerobic wounds (30%), blood (5.5%), urine (22%), cerebrospinal fluid (24%), ophthalmologic cultures (8%), and sterile sites (20%). Organisms deemed clinically significant included multiple Actinomyces species in wounds, Propionibacterium species in joints and cerebrospinal fluid associated with central nervous system hardware, Corynebacterium kroppenstedtii (100%) in breast, and Corynebacterium striatum in multiple sites. Novel findings include clinically significant urinary tract infections by Actinomyces neuii (21%) and Corynebacterium aurimucosum (21%). Taken together, these findings indicate that species-level identification of diphtheroids isolated with a priori suspicion of infection is essential to accurately determine whether an isolate belongs to a species associated with specific types of infection.