Idiopathic granulomatous mastitis mimicking breast cancer: report of two cases

Idiopathic granulomatous mastitis is a rare inflammatory breast disease of unknown aetiology that is frequently mistaken for breast carcinoma both clinically and mammographically. In this paper, the authors report two cases of idiopathic granulomatous mastitis that occurred in two parous women aged 38 and 45 years. Clinically, both patients presented with a tender palpable lump in the left breast. Mammography showed an poorly-defined mass in both patients with microcalcification in the first case and skin retraction in the second case. Breast lumpectomy was performed in both patients. Histological examination of the surgical specimen revealed non-caseating granulomas confined to breast lobules. Special staining for fungi and tuberculosis were all negative. Correct diagnosis ofidiopathic granulomatous mastitis requires the exclusion of malignancy, other granulomatous disease and infectious aetiologies. Histopathologic examination remains the gold standard for diagnosis. This disease is rare, and therefore the optimum treatment protocol is still being established.     

伴反应性肉芽肿的乳腺癌

目的：研究伴反应性肉芽肿的乳腺癌的临床病理特点。方法：观察5例伴反应性肉芽肿的乳腺癌的形态学改变。结果：5例病人都没有全身性肉芽肿性疾病。癌组织内均可见非干酪性肉芽肿,肉芽肿沿癌细胞分布,其内有朗汉斯多核巨细胞区域性淋巴结内没有反应性肉芽肿。结论：伴反应性肉芽肿的乳腺癌需要和乳腺伴破骨细胞样巨细胞的瘤、伴破骨细胞样巨细胞的化生性癌、肉芽肿性小叶性乳腺炎、间质反应性巨细胞、伴结节病或伴结核病的癌鉴别。     

Primary sarcoidosis of the breast: case description and review of the literature

Sarcoidosis is a systemic granulomatous disease of unknown aetiology. The breast is involved in less than 1% of cases. Breast can be either a primary or a secondary site of presentation. Breast sarcoidosis often mimics carcinomas at clinical examination. We report a case of breast sarcoidosis detected during screening mammography in a 57-year-old woman. The lesion presented as a 1.4 cm nodule located in the right breast. On histology, it was characterized by non-caseating giant cell granulomas. Differential diagnoses included idiopathic granulomatous mastitis, tuberculosis, fungal infection, cat-scratch disease and sarcoid-like reactions to cancer. Further clinical and laboratory investigations were consistent with a diagnosis of sarcoidosis. Specifically, serum levels of angiotensin-converting enzyme (ACE) were elevated and a CT scan showed small bilateral pulmonary nodules distributed along the pleura and bronchovascular bundles (perilymphatic pattern), as well as enlarged bilateral hilar and mediastinal lymph nodes. The patient received corticosteroid treatment, and is presently asymptomatic. Breast involvement by sarcoidosis, although rare, should be considered when dealing with granulomatous lesions of the breast.     

A clinicopathological review of 34 cases of inflammatory breast disease showing an association between corynebacteria infection and granulomatous mastitis

AIM: Granulomatous mastitis is a rare condition of unknown aetiology. The great majority of cases has not been associated with bacterial pathogens if women with mammary tuberculosis are excluded. We noted that some women in Auckland with a histological diagnosis of granulomatous mastitis had both microbiological and histological evidence of corynebacteria infection and aimed to study this further. METHODS: Thirty-four women were reviewed who presented with inflammatory breast disease and had microbiological specimens from which corynebacteria were isolated and/or histological specimens containing coryneform bacteria. These 34 cases were compared with 28 controls with similar histology but no evidence of corynebacteria infection. RESULTS: Twenty-seven (79%) of the cases and 21 (75%) of the controls had histological and/or cytological evidence of suppurative granulomas. Fourteen of the 34 cases also had Gram-positive bacilli (GPB), recognisable as coryneform bacteria, in histological sections. In all cases the bacilli were confined to empty spaces, consistent with dissolved lipid, and were surrounded by neutrophils and, frequently, suppurative granulomas. Corynebacterium species were isolated from 52 of 116 microbiological specimens taken from the 34 cases. Forty of these 52 cultures were pure. Twenty-four of the cultures were further classified biochemically and using 16S rRNA gene sequencing. Twenty of the 24 were lipophilic Corynebacterium species and 14 were identified as Corynebacterium kroppenstedtii. The cases were more likely to present with fever or neutrophilia and more often formed sinuses than the controls but other clinical features were similar. Maori and Pacific Islanders accounted for 77% of the women across both groups. CONCLUSION: We suggest granulomatous mastitis can be associated with corynebacteria infection, particularly infection by C. kroppenstedtii. The significance of this finding, which has previously been described in only a single case report, is discussed.     

肉芽肿性小叶性乳腺炎临床病理观察

目的 探讨肉芽肿性小叶性乳腺炎的临床病理特点.方法 对68例经组织病理学证实的肉芽肿性小叶性乳腺炎的临床和组织病理学资料进行回顾性分析.结果 68例患者均为女性,大部分有哺乳史,以乳腺肿块就诊,伴皮肤破溃9例,均不伴特殊感染.组织病理特点为以乳腺终末导管小叶单位为中心的肉芽肿性炎,小叶结构通常存在,小叶内可见以中性粒细胞为主的炎性细胞浸润.随访6～36个月,复发4例.结论 肉芽肿性小叶性乳腺炎与乳腺癌在临床特征上有相似之处,易误诊,须对其镜下组织改变仔细鉴别.     

Granulomatous mastitis caused by histoplasma and mimicking inflammatory breast carcinoma

Two cases of a lobular, necrotizing granulomatous process causing a unilateral painful breast mass mimicking carcinoma are presented for comparison. While the morphologic appearance in each case was that of lobular granulomatous mastitis, the etiologic agent in one case appeared to be Histoplasma capsulatum, based on Grocott methenamine silver staining, and represents the second reported case of histoplasmosis involving only breast parenchyma. Awareness of the rare entity, granulomatous mastitis, is important for the pathologist because the definitive diagnosis is made microscopically. Thorough evaluation of the breast tissue is essential for its management and should eventually contribute to the clarification of its etiology.     

Histopathology of tumour associated sarcoid-like stromal reaction in breast cancer

Summary In 5 cases of invasive ductal and lobular carcinoma of the breast multiple epithelioid and giant cell containing granulomas were detected, localized mainly in circumferential regions, but also in the center of the carcinomas. These granulomas were interpreted as sarcoid-like stromal reactions, occurring as sarcoid-like lesions in uni- and bilateral primaries, in a recurrent tumour, and also in axillary lymph nodes. Histopathologically, these granulomas were not quite uniform, some of them corresponding to typical sarcoidosis, others showing marked proliferations of epithelioid or giant cells or containing fibrinoid exudate or necroses. The granulomas were surrounded by dense infiltrates of mononuclear cells. Tuberculosis and mycosis was excluded. There were no hints of generalized sarcoidosis. Pathogenetically, these are reactions in the tumour stroma of varying intensity, and are not caused by necroses of the tumour tissue nor by microbial infections. Such tumour-associated sarcoid-like stroma reactions are interpreted as a T-cell mediated immune response to an antigen expression of the carcinoma acting as the local trigger; in 2 cases they were connected with sarcoid-like lesions of the axillary lymph nodes. Their occurrence in bilateral carcinoma of the breast points to an immunological disposition for this special kind of host-versus-tumour response. The intensity of these changes in a recurrent tumour reflects an immunological hypersensitivity reaction.The pathogenetic and differential diagnostic aspects of epithelioid granulomas of the female breast in chronic granulomatous mastitis, panniculitis, foreign body reaction, rare infections, and in therapeutically induced sarcoidosis are described and discussed.Dedicated to Prof. Dr. K. Lennert, Kiel, in Honour of his 65th Birthday     

Chronic granulomatous mastitis: review of 26 cases with special reference to chronic lobular mastitis.

Twenty six cases of chronic granulomatous mastitis are reported in a 5 year period and the slides are reviewed. They are sub-classified into Chronic lobular mastitis (CLM), Plasma cell mastitis and subareolar granuloma. There are 10 cases each of CLM and plasma cell mastitis and one of subareolar granuloma. All the three conditions are associated with duct ectasia. Fat necrosis and infective granulomas were 2 each and one of foreign body granuloma. These lesions can be easily differentiated by histology. While most of the CLM occurred in younger age group, plasma cell mastitis is seen in older women. Histologically, there is a florid inflammatory cell reaction of the stroma with dilatation and destruction of some ducts, with microabscess formation. In plasma cell mastitis, the lesion is more chronic with predominance of plasma cells and involutionary changes of the ducts are seen.     

Utility of fine-needle aspiration in the diagnosis of granulomatous lesions of the breast

Fourteen cases of granulomatous mastitis (GM) studied by fine-needle aspiration (FNA) are reviewed and nine cytologic features (necrosis, neutrophil granulocytes, foamy cells, plasma cells, granulomas, epitheloid cells, multinucleated giant cells of foreign body type and Langhans' type, duct cells, and the presence of acid-fast bacilli) are reappraised in a semiquantitative manner. The main objective of this study was to find out if one or more of these features would permit the various granulomatous entities identified in surgical pathology to be separated cytologically. The results suggest that FNA does not permit the various granulomatous lesions identified in surgical pathology to be differentiated, since in this series different entities share a common cytologic pattern. Only the presence of acid fast bacilli in smears would enable a tuberculous etiology to be diagnosed. The opinion is put forward that the term GM should be avoided in the cytologic report and substituted by the noncommitted term “granulomatous lesion of the breast.” Diagn. Cytopathol. 17:108–114, 1997. © 1997 Wiley-Liss, Inc.     

Cystic neutrophilic granulomatous mastitis: an underappreciated pattern strongly associated with gram-positive bacilli

Although granulomatous lobular mastitis is associated with gram-positive bacilli such as Corynebacterium, this association is not well known. We report 3 cases of mastitis caused by gram-positive bacilli. All 3 abscesses were suppurative with distinct enlarged cystic spaces in which rare gram-positive bacilli were identified. Two cases were also granulomatous. Cultures in all 3 cases were negative. All 3 patients recovered after biopsy and tetracycline-based therapy. Infection in the breast by gram-positive bacilli is associated with a distinct histologic pattern, including cystic spaces in the setting of neutrophilic/granulomatous inflammation that can be recognized and should prompt careful search for the organism within enlarged vacuoles.     

Corynebacterium accolens isolated from breast abscess: possible association with granulomatous mastitis

Corynebacterium accolens is rarely isolated as a human pathogen. We describe here a case of C. accolens isolated from a breast abscess in a patient previously diagnosed with granulomatous mastitis. The possible association of Corynebacterium accolens and granulomatous mastitis in this patient is discussed.     

Granulomatous lobular mastitis.

The clinical and pathological features of nine cases of granulomatous mastitis were compared with those of 10 cases of duct ectasia/periductal mastitis (DE/PM), all of which were associated with active granulomatous inflammation. Granulomatous mastitis affects a younger age group, and although there is some overlap with DE/PM, it has distinctive pathological features, particularly a lobule centred distribution, for which the term "granulomatous lobular mastitis" is recommended. There is a strong tendency for persistence or recurrence. Our cases of granulomatous mastitis all occurred in parous women, five of them within three years of pregnancy. Awareness of this condition is important, because surgery does not offer the best treatment of recurrent disease, and trials of adequate drug treatment, including corticosteroids, are required.     

Breast cancer with associated granulomatous axillary lymphadenitis: a diagnostic and clinical dilemma in regions with high prevalence of tuberculosis

Intratumoral granulomas and granulomas in lymph nodes draining breast carcinomas have been reported previously. However, in regions like Pakistan, where the incidence of tuberculosis (TB) is high, it is sometimes difficult to distinguish between TB and a non-specific granulomatous response especially if there is an association with focal necrosis. We present a series of cases of invasive breast carcinoma with an associated granulomatous reaction in lymph nodes with or without necrosis, which were further analyzed for a possible coexisting tuberculosis using special stains and PCR-based assays for the identification of Mycobacterium tuberculosis. Twenty-two cases were examined using ZN stain for AFB and PAS stain for fungal organisms. Nested PCR assays for M. tuberculosis DNA were performed on formalin-fixed, paraffin-embedded tissue. In all the cases, ZN stain for AFB and PAS stain for fungus were negative. M. tuberculosis DNA was detected in 11 (50%) out of the 22 cases. Six of 12 cases which had granulomas in association with necrosis were positive for MTB-DNA, while 5 of 10 cases without necrosis were also positive for MTB-DNA. It is concluded that the presence of granulomas with or without necrosis in association with malignancies should be further evaluated, particularly in regions with a high prevalence of tuberculosis, for the possibility of coexistent tuberculosis, as this may alter the postoperative management of the patient. PCR-based assays are recommended for the diagnosis of TB in cases where ZN is unhelpful for demonstrating AFB or no tissue is submitted for microbiological studies.     

非哺乳期乳腺炎临床特征分析

目的 探讨非哺乳期乳腺炎（NPM）的临床特征。方法 回顾性分析2015年1月~2018年1月我院乳腺外科收治的60例NPM患者的临床资料,总结其临床特点及转归情况。结果 本次研究共纳入60例符合标准的NPM患者,平均发病年龄（35.84±7.38）岁,平均BMI（24.52±4.01）kg/m2,平均初潮年龄（13.42±3.03）岁,平均生育次数（1.20±0.64）次,平均流产次数（0.82±0.10）次,其中左乳患病33例（55.00%）,右乳患病27例（45.00%）,肿块平均直径（4.54±3.82）cm。病理证实乳腺导管扩张症/导管周围乳腺炎48例（80.00%）,肉芽肿性小叶乳腺炎12例（20.00%）。临床随访时间为1年,初次发病接受手术治疗（局部扩大切除）38例,至随访结束均痊愈;非手术治疗22例,至随访结束,4例痊愈,15例肿块大小无进展（缩小或不变）,3例出现进展（其中2例出现窦道）。结论 在乳腺导管扩张症/导管周围乳腺炎病例中,治疗仍以外科手术为主。对于肉芽肿性小叶乳腺炎,推荐类固醇治疗为首选。当有类固醇禁忌症或类固醇治疗无效时,可考虑选择手术切除。     

Sarcoidosis presenting initially as breast mass: report of two cases

The cases of two patients who presented with breast masses suggesting carcinoma and no other clinical features of sarcoidosis are reported. Biopsies in both patients revealed noncaseating, epithelioid granulomas. Mycobacteria, fungi, and foreign material were not identified. In one of the patients, other sites of involvement were discovered five years later. These cases illustrate that sarcoidosis should be considered in patients with granulomatous breast disease, even without evidence of disease elsewhere.     

Chronic granulomatous mastitis in the practice of pathologists

The incidence of chronic mastitis increased 2.3-fold in 2000-2003. This mastitis was diagnosed as mammary carcinoma clinically, roentgenologically and macroscopically in 53.1% patients. Granulomatous component was present in 59.6% cases. On frozen sections it resembled infiltrating carcinoma. Mammary carcinoma was in 3 cases, mycosis and nocardia in 3, oleogranulomas in 23 cases, idiopathic granulomatous mastitis in 12 cases. Review of literature on granulomatous chronic mastitis imitating mammary carcinoma is presented.     

Hepatic pathology of chronic granulomatous disease of childhood.

We reviewed the hepatic pathology of seven cases of chronic granulomatous disease of childhood. All patients were male, with an age range of 5 to 41 years. Hepatic biopsy with drainage or wedge resection was performed in five cases to remove abscesses. Autopsy was performed in three cases. Presentation was typical of infection (fever, leukocytosis) with an elevated serum alkaline phosphatase level. Histologically, the most consistent feature was the presence of foamy macrophages that contained a finely granular golden brown pigment, seen in all seven cases. These were present as small collections predominantly in the portal tracts but were also found in the lobules. Palisading granulomas with central necrosis and associated giant cells were seen in four cases, one of which also had occasional lobular epithelioid granulomas. One case showed hyalinized portal and lobular granulomas. Four cases that showed palisading granulomas cultured positive for Staphylococcus aureus. One case cultured Pseudomonas cepacia, and one case cultured Streptococcus intermedius. Although palisading granulomas are typical of chronic granulomatous disease, they are not seen in all cases. These granulomas are similar to granulomas that are seen with Candida and other fungal infections and therefore are not specific for chronic granulomatous disease of childhood. The pigmented macrophages appear to be a consequence of the primary defect of the disease and are not secondary to infection and associated inflammation.     

Sequential occurrence of different subtypes of nonpuerperal mastitis in contralateral breasts: a report of two cases

Background: Nonpuerperal mastitis (NPM) is a nonspecific chronic inflammation in the breast. The two most common pathologic subtypes are idiopathic granulomatous mastitis (IGM) and plasma cell mastitis (PCM). The cause of NPM is unknown, and the recurrence rate is high; however, the sequential development of two different pathologic subtypes of NPM in contralateral breasts of the same patient is rare. Case summary: Two women who were in their 30 s and with a history of childbearing had an inflammatory mass in one breast, which was identified as PCM by core needle biopsy. However, 1 year after treatment, IGM occurred in the contralateral breast. Histopathologic results after the surgery confirmed both diagnoses. New-onset PCM in both patients was successfully treated with local extended surgical resection and antibiotics combined with incision and drainage. The IGM that developed in the contralateral breast after 1 year was treated with local extended surgical resection and oral steroids. No signs of NPM recurrence were observed in either breast after a follow-up period of more than 1 year. Conclusion: Because recurrence after NPM treatment often occurs in the affected breast, the contralateral breast, which does not often exhibit morbidity factors, is often ignored during treatment follow-up. However, our cases suggest that patients with the occurrence of NPM in one breast should undergo long-term follow-up of the contralateral breast by close monitoring. NPM recurrence should also be considered when there is pain, redness, and swelling in the contralateral breast.     

Surgical pathology of granulomatous interstitial pneumonia

Agranulomatous interstitial pneumonia is a form of diffuse lung disease in which granulomas are a component of the histologic findings. The differential diagnosis is quite broad, but most cases represent examples of either sarcoidosis, diffuse granulomatous infections, or hypersensitivity pneumonitis. "Hot tub lung" is a recently described form of granulomatous interstitial pneumonia that appears to have some features of diffuse infections and some features of hypersensitivity pneumonitis. The pathologist's approach to these conditions can be facilitated by giving careful attention to the anatomic distribution of the granulomas, the qualitative features of the granulomas, and the histologic changes in the lung tissue around and away from the granulomas. These features, along with the results of cultures and special stains for micro-organisms and clinical and radiologic correlation allow for a diagnosis in the vast majority of cases.     

Granulomatous prostatitis: distinction among allergic, nonspecific, and post-transurethral resection lesions

A variety of granulomatous lesions of the prostate, with and without extensive infiltration by eosinophils, have been described. Differing concepts of their pathogenesis, and especially of their relation to allergic states, have produced confusion and controversy. In a review of 62 patients in whom granulomatous lesions in the prostate were diagnosed from 1950 to 1982 at The Johns Hopkins Hospital, the authors identified four major categories. In nine cases specific granulomatous prostatitis was caused by tuberculosis and had typical caseous foci. Nonspecific granulomatous prostatitis was present in 31 cases. These lesions were densely cellular, granulomatous reactions extending throughout entire lobules; three were also characterized by extensive infiltration by eosinophils. Post-transurethral resection granulomas were found in 13 patients who had recently undergone prostatic surgery. These granulomas closely resembled rheumatoid nodules, and four were surrounded by numerous eosinophils. In nine patients the causes of granulomatous prostatitis were varied: two patients had malacoplakia, one had sarcoid, and six had foreign body-type granulomatous. No cases of allergic granulomatous prostatitis were identified. Nonspecific and post-transurethral resection granulomatous prostatitis may both show abundant infiltration by eosinophils and appear histologically identical to the condition that has been described as allergic granulomatous prostatitis; however, in this series both occurred in the absence of asthma or other allergies. The distinction between the rare allergic granulomatous prostatitis, as a reflection of a more generalized allergic reaction, and both post-transurethral resection granulomas and nonspecific granulomatous prostatitis is important, given the differences in clinical outcome and treatment.