Ultrasound-guided vacuum-assisted excision for idiopathic granulomatous mastitis at the abscess stage

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is a rare inflammatory disease of the breast with clinical features that are often confused with those of breast cancer leading to delayed diagnosis and treatment. This retrospective study aimed to evaluate the therapeutic effectiveness and cosmetic results of drainage surgery using ultrasound-guided vacuum-assisted excision (VAE) for the treatment of IGM at the abscess stage.

METHODS

The time of recovery, cases of further surgical intervention, and cosmetic results were retrospectively collected and analyzed from patients who underwent drainage with VAE or conventional drainage between October 2017 and August 2021.

RESULTS

A total of 65 patients diagnosed with IGM at the abscess stage who underwent drainage surgery with VAE or conventional drainage surgery were enrolled. Overall, 38 (58.5%) underwent conventional drainage surgery and 27 (41.5%) underwent drainage with VAE. We found that patients who underwent VAE recovered much faster than those who underwent traditional drainage surgery (30.1 vs. 48.0 days). Nine (33.3%) patients in the VAE group required further surgical intervention after drainage, whereas 33 (86.8%) patients in the control group underwent another surgery to resect residual lesions. Additionally, patients in the VAE group were more satisfied with the breast appearance, mainly due to less influence of the scars and better symmetry of their breasts.

CONCLUSION

Compared with conventional drainage surgery, drainage surgery using VAE for IGM patients at the abscess stage improved therapeutic and cosmetic outcomes. Furthermore, postoperative management of IGM is crucial.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

18 F-FDG PET/CT Imaging of Idiopathic Granulomatous Mastitis

ABSTRACT

A 43-year-old woman, who presented with a suspected left breast abscess, underwent serial ultrasounds, which demonstrated inflammatory changes that were nonresponsive to antibiotics and which spread to the contralateral breast. 18 F-FDG PET/CT demonstrated diffuse heterogeneous intense FDG uptake in both breasts with reactive axillary nodes. Breast biopsy confirmed granulomatous inflammation, and overall findings were consistent with idiopathic granulomatous mastitis. In the absence of histological analysis, idiopathic granulomatous mastitis is an important differential diagnosis to consider for bilateral abnormal breast uptake, and early recognition can facilitate prompt commencement of treatment.

The discriminatory diagnostic value of multimodal ultrasound combined with blood cell analysis for granulomatous lobular mastitis and invasive ductal carcinoma of the breast

OBJECTIVE

To explore the discriminatory diagnostic value of multimodal ultrasound(US) combined with blood cell analysis (BCA) for Granulomatous Lobular Mastitis (GLM) and Invasive Ductal Carcinoma (IDC) of the breast.

METHODS

A total of 157 breast disease patients were collected and divided into two groups based on postoperative pathological results: the GLM group (57 cases with 57 lesions) and the IDC group (100 cases with 100 lesions). Differences in multimodal ultrasound features and the presence of BCA were compared between the two groups. The receiver operating characteristic (ROC) curve was used to calculate the optimal cutoff values, sensitivity, specificity, 95% confidence interval (CI), and the area under the curve (AUC) for patient age, lesion size, lesion resistive index (RI), and white blood cell (WBC) count in BCA. Sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy, and AUC were calculated for different diagnostic methods.

RESULTS

There were statistically significant differences (P < 0.05) observed between GLM and IDC patients in terms of age, breast pain, the factors in Conventional US (lesion size, RI, nipple delineation, solitary/multiple lesions, margin, liquefaction area, growth direction, microcalcifications, posterior echogenicity and abnormal axillary lymph nodes), the factors in CEUS (contrast agent enhancement intensity, enhancement pattern, enhancement range, and crab-like enhancement) and the factors in BCA (white blood cells, neutrophils, lymphocytes and monocytes). ROC curve analysis results showed that the optimal cutoff values for distinguishing GLM from IDC were 40.5 years for age, 7.15 cm for lesion size, 0.655 for lesion RI, and 10.525*109/L for white blood cells. The diagnostic accuracy of conventional US combined with CEUS (US-CEUS) was the highest (97.45%). The diagnostic performance AUCs for US-CEUS, CEUS, and US were 0.965, 0.921 and 0.832, respectively.

CONCLUSION

Multifactorial analysis of multimodal ultrasound features and BCA had high clinical application value in the differential diagnosis of GLM and IDC.

Framework and guide for intralesional steroid injections in idiopathic granulomatous mastitis

PURPOSE

Literature on how to perform intralesional steroid injections, a valuable therapy for idiopathic granulomatous mastitis (IGM), is limited. This technical note offers a detailed technical guide on intralesional steroid injections for IGM and provides a framework for long-term follow-up.

METHODS

Ultrasound characterization of IGM severity considering breadth, depth, and ancillary findings was used to guide steroid dosing and injection frequency. Clinical and sonographic breast diagrams were designed for accurate longitudinal tracking of IGM. A step-by-step guide for ultrasound-guided IGM aspirations and intralesional steroid injections was developed.

RESULTS

A detailed approach for ultrasound-guided IGM interventions with clinical and sonographic breast diagrams for longitudinal follow-up is now in practice.

CONCLUSIONS

The treatment approach described provides a framework for multidisciplinary treatment of IGM and offers insights that may contribute to the ongoing development and improvement of management strategies for this challenging disease.

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

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

[Idiopathic granulomatous mastitis and breast carcinoma: What difference on elastography?]

OBJECTIVES

To determine the elastographic characteristics of idiopathic granulomatous mastitis compared to breast carcinoma.

MATERIALS AND METHODS

Retrospective study of 63 breast masses. Ultrasound B mode and strain elastography were performed for each mass. Qualitative criteria (strain score) and semi-quantitative criteria (strain and length ratio) of strain elastography were studied. The pathological findings were used as the reference standard.

RESULTS

Sixty-three breast masses, there were 15 idiopathic granulomatous mastitis and 48 breast carcinomas. The mean strain ratio of idiopathic granulomatous mastitis was significantly lower than that of breast carcinoma, respectively 3.34±2.50 and 21.22±20.57 (P<0.0001). However, there was no significant difference between the mean length ratio of idiopathic granulomatous mastitis and breast carcinoma, respectively 1.17±0.18 and 1.22±0.23 (P=0.381).

CONCLUSION

Breast elastography helps to differentiate idiopathic granulomatous mastitis from breast carcinoma.

The effectiveness of methotrexate and low-dose steroid therapy in the treatment of idiopathic granulomatous mastitis

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is a rare, chronic, benign, inflammatory breast disease of unknown cause. Patients usually present with a single breast mass, hyperemia, discharge, skin disorders, and fever. Radiological and clinical findings can mimic carcinoma and infection.

OBJECTIVES

To examine the treatment of IGM with methotrexate (MTX) + low-dose steroid, and present the results and follow-up data from our center.

MATERIAL AND METHODS

Sixty-two patients, diagnosed with IGM in our center between January 2009 and December 2017 were included in this study. Patients diagnosed with granulomatous mastitis histopathologically underwent testing with anamnesis, physical examination and imaging methods to exclude other diseases that cause granulomatous reactions. Patients with a history of malignancy, chronic infectious diseases such as hepatitis B and pregnant women were excluded from this study. Data collected from 62 patients were reviewed retrospectively for this study.

RESULTS

The mean patient age was 36.58 ±5.83 years (range: 28-54 years). Lesions were present in the right breast in 30 (48.38%) patients, the left breast in 26 (41.94%) patients and both breasts in 6 (9.68%) patients. Methotrexate was administered orally at a dose of 15 mg/week and methylprednisolone at a dose of 8 mg/day. The mean clinical and radiological remission periods of these patients were 10.14 ±1.21 months (range: 3-14 months). All patients attended regular follow-up appointments. The recovery rate of patients during follow-up was determined to be 93.71%.

CONCLUSION

Methotrexate + low-dose steroid therapy is successful in the treatment of IGM. Prospective, large case series and/or multi-center studies are needed to develop an IGM treatment algorithm.

The Role of Shear Wave Elastography in Differentiating Idiopathic Granulomatous Mastitis From Breast Cancer

INTRODUCTION

Shear wave elastography (SWE) uses focused radiation forces without manual compression and is intrinsically not operator dependent. Shear waves travel faster in stiffer tissue and slower in softer tissues.

PURPOSE

The purpose of this study was to determine the role of SWE, imaging, and point measurements in differentiating idiopathic granulomatous mastitis (IGM) from breast cancer.

MATERIAL AND METHODS

Data from 168 patients diagnosed with breast cancer (n= 80) or IGM (n = 88) through image-guided biopsy were included in the study. All patients were evaluated with SWE followed by conventional ultrasonography (US). Shear wave velocity (Vs) and the SWE scoring system (Tsukuba) were used to evaluate lesions, which were classified synchronously according to the Breast Imaging Reporting and Data System (BI-RADS) by using conventional US. Lesion size and BI-RADS scores were recorded, and the scores of the lesions were compared between the two groups. The diagnostic capacity of the Vs value was measured by the area under the receiver operating characteristic curve (AUC, 0.94).

RESULTS

The mean age was 37 ± 9 years for patients with IGM and 49 ± 13 years for patients with breast cancer. Both Breast Imaging Report and Data System (BI-RADS) and SWE scores were significantly higher in breast cancer patients than in IGM patients (p < 0.01). However, unlike the Vs values and SWE scores, the BI-RADS scores were not low enough in many IGM cases to avoid biopsy. The mean Vs value of IGM lesions was 2.5 ± 1.17 m/s, which was significantly lower than that of breast cancer (5.2 ± 0.76 m/s, p < 0.01). The cut-off value was 4.1 m/s, and the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 97.5%, 93%, 92.6%, 97.6%, and 95.2%, respectively (p < 0.01).

CONCLUSION

SWE has high sensitivity and specificity in differentiating IGM from breast cancer with a lower SWE score and Vs value. Implementing this approach in clinical practice could reduce the number of unnecessary biopsies.

Comparison of the efficiency of systemic therapy and intralesional steroid administration in the treatment of idiopathic granulomatous Mastitis. The novel treatment for Granulomatous Mastitis

BACKGROUND

Idiopathic granulomatous mastitis that has not had a clear consensus about its treatment since the day it was identified as a rare, benign inflammatory breast disease that mimics malignancy due to its appearance features.

AIMS

In our research, we intended to compare the efficiency of intralesional and systemic steroids administration in the treatment of idiopathic granulomatous mastitis.

STUDY DESIGN

Prospective randomized controlled study.

METHODS

A total of 36 female patients who had been histopathologically diagnosed with idiopathic granulomatous mastitis and whose other factors had been microbiologically excluded were included in the study. The patients were randomized into two sub-groups that would be treated with systemic and intralesional steroids. All patients were evaluated through physical examination one week after the completion of the treatment. Subsequently, the follow-up of the patients was performed thorough physical examination and ultrasonography and/or magnetic resonance imaging at the 1st, 3rd, and 6th months.

RESULTS

All patients adapted to treatment. Complete clinical regression occurred in 32 patients, while 30 of 36 patients responded to treatment both radiologically and clinically. A total of 4 patients had minor side effects. It was determined that there was no statistically significant difference between local and systemic steroid groups in terms of complete clinical regression, responded to treatment side effects, and recurrence rates.

CONCLUSION

Intralesional steroid administration was also considered just as a successful treatment method as the systemic steroid administration.

KEY WORDS

Idiopathic granulomatous mastitis, Intralesional steroid, Systemic steroid.

Granulomatous Mastitis: What Radiologists Should Know With Imaging Examples of Biopsy Proven Cases

ABSTRACT

Granulomatous mastitis is a rare benign inflammatory disease of the breast, predominantly affecting women of childbearing age. Because of its low prevalence, the literature is limited, and its treatment algorithm is unclear. However, it is important to understand this disease for timely diagnosis and treatment. Our overview with imaging examples of biopsy-proven cases aims to improve our knowledge and to determine when it would be appropriate to include it in the differential diagnosis.

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.

Granulomatous mastitis: etiology, imaging, pathology, treatment, and clinical findings

PURPOSE

To outline the demographics, clinical presentation, imaging features, and treatment modalities observed among a series of patients diagnosed with biopsy-proven granulomatous mastitis (GM).

METHOD

Following approval by institutional review board, retrospective chart review was performed on patients with biopsy-proven granulomatous mastitis at our institution in the period from January 2013 until October 2017.

RESULTS

A total of 90 patients were identified: 87 women and 3 men. The mean age was 35 years, mostly women in their reproductive age. In our study, patients with GM were more likely to be Hispanic compared to the general population. Sixty-three percent of patients were within 5 years of previous pregnancy. Painful palpable mass-like lesion was the most common physical finding. Breast ultrasound (US) was performed in all patients, and most commonly showed a hypoechoic irregular-shaped mass. Mammography (MG) showed asymmetry or irregular mass as the main finding. Definitive diagnosis was obtained by imaging-guided core needle biopsies in 94.4%. Conservative management was preferred, and only one patient underwent surgery.

CONCLUSION

Although clinical and radiological findings of patients with GM may mimic those of breast carcinoma, our study showed that women of childbearing age, especially among Hispanic ethnicity with a recent history of pregnancy or high prolactin level and newly tender mass-like lesion, in addition to new focal asymmetry on mammogram and heterogeneous hypoechoic irregular-shaped mass on ultrasound exam, should raise concern for GM. Non-invasive approach and clinical follow-up were the preferred treatment method.

Advantages of b-mode ultrasound combined with strain elastography in differentiation of idiopathic granulomatous mastitis from malignant breast lesions

Background/aim: To evaluate the diagnostic performance of strain elastography (SE) combined with B-mode ultrasound in distinguishing between idiopathic granulomatous mastitis (IGM) and malignant breast lesions. Materials and methods: Seventy-seven malignant breast lesions and 36 IGM were assessed using B-mode ultrasound and SE. Ultrasonographic findings for all the breast lesions were classified based on the 2013 American College of Radiology Breast Imaging Reporting and Data System (BI-RADS-US), and the SE findings were evaluated based on the strain ratio and a five-point scale. The diagnostic performances of B-mode ultrasonography, SE, and the combination of both methods were compared. Results: Significant differences in strain ratio and elastography scores were found between IGM and malignant breast lesions. When the lesions were assessed with B-mode ultrasound alone, in order to distinguish between IGM and malignant breast lesions, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 94.8%, 66.7%, 85.9%, 85.7%, and 85.8%, respectively. However, when assessed with a combination of B-mode ultrasonography and SE, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 96.1%, 100%, 100%, 92.3%, and 97.3%, respectively. Conclusion: The combination of SE and B-mode ultrasound has better diagnostic performance in the differentiation of IGM and malignant breast lesions than B-mode ultrasonography alone.

Is there a correlation between the severity of Idiopathic Granulomatous Mastitis and pre-treatment Shear-Wave Elastography Findings? Original research

AIM

The aim of this study was to analyze the correlation between the severity of idiopathic Garulomatous Mastitis (IGM) and the pre-treatment Shear-Wave Elastography (SWE) findings.

MATERIAL AND METHODS

A total of 39 patients diagnosed with granulomatous mastitis were included in the study between the dates of December 2014 and February 2017. The patients were divided into two groups. Group 1 was treated using a conservative protocol and steroids. Group 2 was treated surgically. Pre-treatment SWE findings of both groups were compared.

RESULTS

The mean ages of the patients in group 1 and 2 were 38.44±9.6 and 36.05±7.44 years, respectively. There were not any significant differences between the groups with regard to frequency of BI-RADS categories and Virtual touch tissue imaging (VTI) patterns. The mean Shear-Wave Spead (SWS) were 1.98 ± 1.02 m/sec and 2.82± 1.66 m/sec in group 1 and 2 respectively. The difference was not significant (p ≥ 0.05). The BI-RADS categories and VTI patterns did not show significant difference when the recurrent and non-recurrent patients were compared.

CONCLUSION

There may not be a correlation with the pre-treatment SWE findings and severity of the IGM.

KEY WORDS

Breast, Elasticity Imaging Techniques, Granulomatous mastitis, Ultrasonography.

Granulomatous Mastitis in a Transgender Patient

Granulomatous mastitis is a rare and benign inflammatory condition of the breast most commonly affecting women of child-bearing age as well as patients on oral contraceptives. This condition is important to identify due to its diagnostic mimicry of malicious entities such as breast carcinoma. Clinical and radiological findings are nonspecific and may overlap with breast carcinomas, thus pathologic confirmation is often necessary for definitive diagnosis. Although cases of granulomatous mastitis have been described in cisgender females, there have been no reported cases in the transgender patient, a growing patient population with few imaging guidelines. Transgender patients are at risk of developing this breast entity due to the use of long-term hormone treatments or presence of residual breast tissue. A trial of antibiotics or steroids may be administered. However, surgical treatment is often necessary in recurrent or refractory cases.

Differential diagnosis of idiopathic granulomatous mastitis and breast cancer using acoustic radiation force impulse imaging

PURPOSE

Differentiation of idiopathic granulomatous mastitis (IGM) from carcinoma with routine imaging methods, such as ultrasonography (US) and mammography, is difficult. Therefore, we evaluated the value of a newly developed noninvasive technique called acoustic radiation force impulse imaging in differentiating IGM versus malignant lesions in the breast.

METHODS

Four hundred and eighty-six patients, who were referred to us with a presumptive diagnosis of a mass, underwent Virtual Touch tissue imaging (VTI; Siemens) and Virtual Touch tissue quantification (VTQ; Siemens) after conventional gray-scale US. US-guided percutaneous needle biopsy was then performed on 276 lesions with clinically and radiologically suspicious features. Malignant lesions (n = 122) and IGM (n = 48) were included in the final study group.

RESULTS

There was a statistically significant difference in shear wave velocity marginal and internal values between the IGM and malignant lesions. The median marginal velocity for IGM and malignant lesions was 3.19 m/s (minimum-maximum 2.49-5.82) and 5.05 m/s (minimum-maximum 2.09-8.46), respectively (p < 0.001). The median internal velocity for IGM and malignant lesions was 2.76 m/s (minimum-maximum 1.14-4.12) and 4.79 m/s (minimum-maximum 2.12-8.02), respectively (p < 0.001).

CONCLUSION

The combination of VTI and VTQ as a complement to conventional US provides viscoelastic properties of tissues, and thus has the potential to increase the specificity of US.

Rhodococcus equi granulomatous mastitis in an immunocompetent patient

A 37-year-old immunocompetent woman was evaluated for progressive swelling of her left breast. Magnetic resonance imaging (MRI) showed multiple hypo-intense solid lesions and could not exclude breast cancer. Tissue biopsy was suggestive of granulomatous mastitis without any evidence of malignancy. Culture of the specimen in brain heart infusion broth grew Rhodococcus equi. The patient responded well to combination therapy with ciprofloxacin and azithromycin, and the lesions regressed in follow-up MRI. To the best of our knowledge, this is the first report of R. equi granulomatous mastitis. Accurate identification of this rare pathogen is necessary to provide appropriate treatment in granulomatous mastitis.