Idiopathic granulomatous mastitis: a diagnostic dilemma

Refractory and Recurrent Idiopathic Granulomatous Mastitis Treatment: Adaptive, Randomized Clinical Trial

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is mostly described as an autoimmune disease with higher prevalence among Middle Eastern childbearing-age women. This study aimed to evaluate the best treatment of choice in patients with resistant or recurrent IGM.

STUDY DESIGN

Patients with established recurrent or resistant IGM who were referred to the Breast Cancer Research Center from 2017 to 2020 were randomly assigned to either one of the following treatment groups: A (best supportive care), B (corticosteroids: prednisolone), and C (methotrexate and low-dose corticosteroids). This adaptive clinical trial evaluated radiological and clinical responses, as well as the potential side effects, on a regular basis in each group, with patients followed up for a minimum of 2 years.

RESULTS

A total of 318 participants, with a mean age of 33.52 ± 6.77 years, were divided into groups A (10 patients), B (78 patients), and C (230 patients). In group A, no therapeutic response was observed; group B exhibited a mixed response, with 14.1% experiencing complete or partial responses, 7.7% maintaining stability, and 78.2% experiencing disease progression. Accordingly, groups A and B were terminated due to inadequate response. In group C, 94.3% achieved complete response, 3% showed partial remission, and 2.7% had no response to therapy. Among the entire patient cohort, 11.6% tested positive for antinuclear antibodies, 3.5% for angiotensin-converting enzyme, and 12.3% for erythema nodosum. Notably, hypothyroidism was a prevalent condition among the patients, affecting 7.2% of the cohort. The incidence of common side effects was consistent across all groups.

CONCLUSIONS

The most effective treatment option for patients with recurrent or resistant IGM is a combination therapy involving steroids and disease-modifying antirheumatic drugs such as methotrexate.

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.

Clinicopathological evaluation of idiopathic granulomatous mastitis patients: A retrospective analysis from a tertiary care hospital in Turkey

Idiopathic granulomatous mastitis (IGM) is a chronic inflammatory disease of the breast with unknown etiology that is characterized by granuloma formation. We analyzed the clinical, radiological, and therapeutic approaches; the recurrence rate of the disease; and the pathological findings diagnosed with mastitis in a retrospective study. We evaluated a total of 77 patients subjected to core needle or excisional biopsy with preliminary diagnosis of mastitis between January 2017-December 2019 who diagnosed with IGM, nonspecific mastitis/abscess, or periductal mastitis/plasma cell mastitis as a result of their pathological assessment. The mean age was 39.24 ± 10.6. Though 65 patients were diagnosed with IGM (84.4%), other diagnoses were reported as nonspecific mastitis/abscess (n = 9), periductal mastitis (n = 2) and plasma cell mastitis (n = 1). Recurrence occurred in 30 (39%) patients during follow-up. In patients without IGM, the number of 5-year postpartum mastitis diagnoses was significantly higher (p = 0.0008) while number of 2-year postpartum mastitis diagnoses was lower (p = 0.255) compared to those in IGM patients. The rates of axillary lymphadenopathy, bacterial culture, parity, and menopausal status were not different in patients without IGM. Linear correlation analysis did not reveal a significant relationship between radiological preliminary diagnosis and pathological diagnosis with BI-RADS classification. A detailed assessment, accompanied with clinical, radiological, and pathological findings, should be performed to achieve an accurate diagnosis and effective patient management in IGM. Furthermore, IGM should always be considered in the differential diagnosis of mastitis among breast masses.

An update on granulomatous mastitis: a rare and complex condition

Granulomatous mastitis is a rare inflammatory condition of the breast affecting women of child-bearing age. The disease is characterised by chronic and relapsing inflammation, resulting in scarring and discharging sinuses. Granulomatous mastitis is considered to be idiopathic and the pathogenesis is poorly understood. An amplified immune response has been proposed as a likely cause and there is evidence linking Corynebacterium to some cases of granulomatous mastitis. The presentation is similar to bacterial mastitis or abscess and antibiotics are commonly commenced empirically. The cornerstone of diagnosis is histopathological evaluation on core biopsy; an index of suspicion based on demographic assessment can avoid delays in diagnosis. Management is difficult and there is no consensus on best treatment. Various treatment regimens are described, with high relapse rates relating to the nature of the condition. Watchful waiting is appropriate for mild presentations and steroids are the mainstay of treatment for more severe cases. This article reviews the emerging evidence on granulomatous mastitis and describes an updated approach to management.

Idiopathic granulomatous mastitis: challenges of treatment in iranian women

BACKGROUND AND OBJECTIVE

As a chronic inflammatory disease of an unknown origin, the treatment of granulomatous mastitis has always been controversial. According to some researchers, surgical treatment and certain medications, especially steroids, are more effective in treating the disease. This study aimed at evaluating the results of treatment in a group of patients with granulomatous mastitis.

MATERIALS AND METHODS

This longitudinal cohort study evaluated the treatment outcomes of 87 patients with pathology-confirmed granulomatous mastitis referred to the surgical clinic of Central Hospital in Sari, Iran. Demographic, clinical, and pathological information, treatment methods and results, and the recurrence rate were analyzed.

FINDINGS

A total of 87 female patients with granulomatous mastitis aged 22-52 years with a mean age of 34 years were evaluated. All patients had palpable masses; the breast masses were painful in 48.3% of patients, and 55.2% of patients suffered from erythema and inflammation, and8% had fistulas and ulcers at the inflammation site. The patients were followed-up for an average duration of 26 months (8-48 months) after treatment and recovery. The overall recurrence rate was 24.1%, and the recurrence rate was 29.4% in patients underwent surgery, 34.8% in patients received high-dose prednisolone, and 17% in those received low-dose prednisolone together with drainage (p < 0.001).

CONCLUSIONS

According to the results, the low-dose prednisolone plus drainage was more effective with a lower recurrence rate than only surgical excision or high-dose prednisolone. In fact, the use of minimally invasive methods such as drainage plus low-dose steroids is a more effective method with fewer side effects than the other two methods.