Methotrexate in the management of granulomatous mastitis

Granulomatous mastitis is a rare benign inflammatory breast disease that often clinically simulates carcinoma. Surgical resection of the entire lesion has been the main method of treatment but recurrence, infection, sinus formation and delayed wound healing can occur relatively commonly. Corticosteroids are also effective in recurrent or resistant cases but are associated with side-effects and relapse of disease after steroid withdrawal. A low weekly oral dose of methotrexate was used in five resistant cases after surgery plus corticosteroid. All cases achieved remission, withdrawal of corticosteroid without relapse and no methotrexate side-effect.     

Cystic neutrophilic granulomatous mastitis: The Cleveland Clinic experience with diagnosis and management

Granulomatous mastitis is an uncommon inflammatory disease that typically presents with painful breast lesions. Recent publications have brought to light a specific subset of granulomatous mastitis patients with a distinct histological pattern of disease termed, “cystic neutrophilic granulomatous mastitis” (CNGM). Although many cases of granulomatous lobular mastitis have been thought to be idiopathic, this rare subset of an uncommon disease has been linked to infections with Corynebacterium species. Herein, a cohort of CNGM patients from a large, tertiary care, North‐American, academic medical center is presented. Correlative demographic, clinical, radiographic, pathologic, microbiologic, management, and outcomes data are provided. Collaborative communication between specialists to accurately diagnose and manage these patients is essential to decreasing potential morbidity.     

Radiologic features of granulomatous mastitis

Granulomatous mastitis (GM) is a recognized, but an uncommon cause of breast mass. Awareness of this condition is important, because it can clinically as well as radiologically mimic breast carcinoma. In this study, we present the imaging features of a series of 10 cases with proved diagnosis of granulomatous mastitis with emphasis on magnetic resonance (MR) findings. All those patients who were histologically proven to have GM of the breast were analyzed. Their files were reviewed and data recorded for demographic, clinical presentation and imaging appearances. The imaging features of the lesions by mammography, ultrasound, and magnetic resonance imaging were analyzed. Of the 305 patients who were surgically treated, 10 (3%) cases proved to have GM. All the patients were females with age ranging from 27 to 53 years (average 38 years and median age 36 years). Guided core biopsy was performed in all cases for confirmation of diagnosis followed by either excision biopsy (in five cases) or lumpectomy (in five cases). The final histopathologic results were chronic granulomatous inflammation consistent with tuberculosis in four cases and GM with acute inflammation, but unknown etiology in four cases and GM due to duct ectasia in two cases. GM, a rare breast condition, should be considered in the differential diagnosis of patients with a breast mass associated with inflammatory change. Routine breast imaging with US, MG, or MRI, the condition from malignant lesions and biopsy, still remains the only method of definite diagnosis.     

Idiopathic granulomatous mastitis: A systematic review of 3060 patients

Idiopathic granulomatous mastitis is a rare benign breast disease. A systematic review was designed. Clinical and therapeutic characteristics were analyzed. Human Development Index (HDI) was used to define two groups of study: group A (very high and high HDI) and group B (medium and low HDI). Corticosteroid therapy was done in 69% group A and 78% group B. Surgery was done in 63% in group A and 83% in group B. Antibiotics were used in 68% group A and 88% group B. There is no consensus about optimal treatment for granulomatous mastitis.     

Granulomatous mastitis

Granulomatous mastitis is a rare, benign breast disease that can mimic carcinoma. This report describes the clinical and pathological features of two patients presenting with breast abscesses. Both patients required a drainage procedure for the abscesses before a definite diagnosis could be made. Granulomatous mastitis must also be differentiated from other known causes of granulomatous inflammation such as tuberculosis, which is common in Hong Kong. The management of granulomatous mastitis remains controversial. Surgery alone may not prevent subsequent recurrence. Nevertheless, it is important to have operative specimens examined histologically so that a patient’s prognosis can be better understood.     

Idiopathic granulomatous mastitis: surgery, treatment, and reconstruction

Idiopathic granulomatous mastitis is a rare inflammatory breast disease that mimics breast diseases such as inflammatory breast carcinoma, infective mastitis, and inflammatory breast disease of known cause. It is a diagnosis made only after excluding other causes, and although the disease is nonmalignant it may be both locally aggressive and recurrent. Definitive treatment may require radical excision and adjunctive treatment with immunosuppressants. Reconstruction following excision of disease has not been previously described. In those patients who undergo reconstruction, both the surgeon and the patient must be aware of complications associated with residual disease, and the potential involvement of donor sites. Treatment should be undertaken as part of a multidisciplinary team including surgeons and physicians with an interest in inflammatory breast disease. We present two patients diagnosed with idiopathic granulomatous mastitis who were referred to our unit for consideration of reconstruction. One patient underwent autologous breast reconstruction and the other contra lateral surgery to achieve symmetry.     

Idiopathic granulomatous mastitis: time to avoid unnecessary mastectomies

Idiopathic granulomatous mastitis is a rare disease of the breast. Clinically and radiologically it may mimic breast carcinoma. Awareness of surgeons, pathologists, and radiologists is essential to avoid unnecessary mastectomies. Data regarding 24 patients with histologically confirmed idiopathic granulomatous mastitis treated at our center over 8 years were analyzed. The mean age of patients was 34.3 years. Breast lump was the most common presentation. The right breast was affected in 16 cases. Four patients were pregnant at the time of presentation. Lactation within 6 months of presentation was documented in four patients. Two patients used contraceptives pills. A clinical suspicion of malignancy was present in 17 cases. Mammography was performed in 16 patients and showed focal asymmetrical dense lesions in 9, well-circumscribed opacity in 4, spiculated lesion in 1, and was normal in 2. Fine-needle aspiration was performed in 17 patients, of which 2 were reported as malignant. Wide local excision was the mainstay of treatment. One patient underwent mastectomy upon clinical, mammographic, and repeated cytologic findings consistent with malignancy, and the final histology confirmed idiopathic granulomatous mastitis with no evidence of malignancy. Four patients developed recurrence after a mean follow-up of 31.2 months. A greater awareness of the rare entity of idiopathic granulomatous mastitis is mandatory to avoid unnecessary mastectomies. Clinical, radiologic, and even cytologic findings are sometimes confused with malignancy. To the best of our knowledge, our patient who developed the disease at the age of 11 years is the youngest reported case.     

The effect of methotrexate monotherapy on treatment-resistant idiopathic granulomatous mastitis patients

BackgroundIdiopathic granulomatous mastitis (IGM) is a disease of unknown etiology, involving a chronic inflammatory process, characterized by noncaseating granuloma formation. IGM can mimic a tumor clinically and radiologically. Since we are a tertiary referral center, most of our patients (n = 56, 87.5%) are secondary admissions who have previously had antibiotics and steroid treatments; therefore, we accept these patients as resistant cases. Here, we aim to present our single-center series of 64 patients with resistant IGM who underwent methotrexate monotherapy. To the best of our knowledge, our study includes the highest number of patients described in the literature with IGM who have undergone this treatment.MethodsThis study included 64 patients, 56 of which were resistant cases, diagnosed with IGM between January 2013 and January 2020 at Istanbul University Cerrahpasa, Cerrahpasa Medical Faculty, General Surgery Breast Outpatient Clinic that were followed-up at least once. These patients were administered oral methotrexate monotherapy 15 mg/week for 24 weeks, and in relapsed cases, the treatment was up to 20 mg/week for 1 year. Folic acid 10 mg/week was given as a supplement to all patients.ResultsComplete recovery was observed in 52 (81.25%) of the 64 patients. Follow-up was discontinued by 4 patients. The dose was increased and the duration of treatment was extended up to 1 year when relapse was observed in 8 patients and complete response was then obtained in these cases. Only 3 patients (4.69%) experienced side effects and were switched to subcutaneous treatment due to nausea.ConclusionConsidering the high patient compliance, low recurrence, minimal side effects, and overall success of the treatment, we believe that methotrexate monotherapy may be used in treatment-resistant IGM patients and may also be the first choice for first-line treatment in the future.     

Methotrexate in the management of idiopathic granulomatous mastitis: review of 108 published cases and report of four cases

This study aimed to discuss the role of agents, such as steroids and methotrexate (MTX), in the treatment of patients with idiopathic granulomatous mastitis (IGM). Using Pubmed and Google Scholar data bases, a retrospective study was carried out on IGM cases treated with steroids and/or MTX between 1972 and 2010. Four IGM cases treated with MTX at our clinic were also summarized in this study. A total of 541 IGM cases since 1972, including ours, were retrospectively analyzed. Steroid treatment 5-85 mg was administered over 5 days-22 months to 112 patients aged 21-48 years. Recurrence occurred in 22 patients, steroid-induced diabetes mellitus in 5 patients, no response to treatment was observed in 4 patients, in 2 patients, the mass decreased in size, and static disease was observed in one. The steroid treatment was changed to MTX treatment in 4 patients who had recurrence, 5 with steroid-induced DM and in 4 who were nonrespondents. Three patients were started on steroid together with MTX as a primary treatment. Of the patients treated with MTX, a satisfactory result was obtained in 14 cases and in 2, mastectomy was performed because of recurrence despite the treatment with MTX. IGM is a troublesome condition that presents management problems due to the side effects of steroids. Our study demonstrates that the use of MTX in IGM cases has been effective in preventing complications, in resolving the inflammatory process, and in limiting side effects of corticosteroids.     

难治性特发性肉芽肿性乳腺炎病例报告及文献综述

【摘要】〓目的〓介绍三例难治性特发性肉芽肿性乳腺炎(IGM)的诊治经过及治疗效果并文献综述。方法〓三例难治性IGM患者均为年轻生育后女性,均因乳房肿块伴红肿及局部破溃甚至窦道形成等弥漫病变就诊,脓液细菌培养阴性,其中2例患者应用“三联抗分支杆菌”药物联合甲泼尼龙片治疗,1例患者接受甲泼尼龙联合甲氨蝶呤治疗。结果〓三例患者均得到10个月随访,1例接受“三联抗分支杆菌”药物及甲泼尼龙的患者最终行肿块切除及乳头内陷矫正术后痊愈,其他2例患者均保守治疗后痊愈。结论〓“三联抗分支杆菌”或免疫抑制剂联合类固醇激素治疗难治性特发性肉芽肿性乳腺炎的效果良好,但前者用药证据较难获得。     

46例肉芽肿性乳腺炎的声像图分析

目的探讨肉芽肿性乳腺炎(GM)的声像图特征及临床意义。方法对46例经病理证实的GM的超声表现进行回顾性分析。结果超声表现为不均匀的低回声,39例边界不清,形态不规则,其中13例主要表现为多个管道回声延续,26例主要表现为成角和分叶。4例边界清楚,形态尚规则。4例呈现为囊性回声,内见细点状中强回声。余3例主要表现为弥漫性腺体回声紊乱。CDFI示大部分病灶可探及血流信号,但血流信号不十分丰富,3例病灶无血流信号。39例伴有腋下淋巴结肿大。结论 GM的主要超声表现为不均匀的低回声,内可有管道样回声,边缘成角或分叶,病灶内常可探及血流信号,具有一定的超声特征及临床意义。     

特发性肉芽肿性乳腺炎磁共振误诊1例分析并文献回顾

【摘要】 目的 提高对特发性肉芽肿性乳腺炎(IGM)临床以及磁共振表现的认识,避免对该病的误诊。方法 报告我院1例术前磁共振误诊的特发性肉芽肿性乳腺炎的临床表现、辅助检查结果及超声、磁共振表现,并结合文献进行复习,分析误诊原因。结果 入院后对患者进行血常规、超声、磁共振等检查后,行乳腺病灶区段切除术,术后恢复良好。结论 特发性肉芽肿性乳腺炎术前磁共振诊断较难,但其磁共振表现仍有一定特异性,若出现相应征象,应考虑到该病可能,将有助于患者的治疗。     

31例肉芽肿性乳腺炎的临床诊治分析

目的探讨肉芽肿性乳腺炎的病因,临床特点,以及诊治方法 ,指导临床实践。方法收集我院2007年6月至2010年1月间住院治疗的31例肉芽肿性乳腺炎。分析其临床、病理特点,以及诊治经过。结果在该研究组中30例(97%)患者有生育史,且11例(35%)有积乳病史。85%(25/29)在产后6年内发病,中位发病间隔期为3年。79%(22/28)不伴有白细胞计数的升高。病理检查病灶为多灶性。93%(29/31)的病例通过I期或II期手术切除病灶得以治愈。结论使用抗生素联合皮质类固醇激素治疗可控制肉芽肿性胰腺炎的病情进展。病灶切除术是根治该病主要方法 。     

Surgical treatment of granulomatous mastitis: Our experience in Bahrain

Granulomatous mastitis (GM) is a rare, benign inflammatory disease of the breast with unknown etiology. There is no universally accepted treatment for GM. The aim of this study was to show our experience with surgical treatment of GM. A retrospective review was performed for 29 cases that were surgically treated at Salmaniya Medical Complex (SMC) in Bahrain between 2010 and 2017. All patients underwent surgical excision with debridement and removal of retroareolar ductal system. None of these patients experienced recurrence in the follow‐up period. Complete surgical excision of the whole inflammatory mass is the treatment of choice.     

泼尼松在肉芽肿性小叶性乳腺炎中的应用

目的探讨肉芽肿性小叶性乳腺炎临床病理特征及泼尼松治疗的临床疗效。方法对14例肉芽肿性小叶性乳腺炎患者临床病理特征及预后进行回顾性分析。结果 85.7%的患者在产后1～4年发病,平均随访时间11.7个月,临床最常见的症状是乳腺肿块及疼痛,影像学表现为非特异性改变,泼尼松治疗2周后缓解率为92.9%,54.5%患者停药后获得治愈并最终免除手术,未观察到患者复发。结论肉芽肿性小叶性乳腺炎好发于育龄期经产妇女,泼尼松治疗可使大部分患者免除手术获得治愈。     

特发肉芽肿性乳腺炎24例的诊断与治疗

目的 探讨特发肉芽肿性乳腺炎的临床特点及处理方法.方法 总结2002年1月-2010年6月经穿刺病理证实及手术治疗的24例特发肉芽肿性乳腺炎的病例资料并对相关文献进行复习.结果 该研究组24例,患者平均年龄为34.5岁,不同时期表现为乳腺包块、脓肿、窦道形成.影像学检查很难将乳腺炎性介质反应和乳腺肿瘤鉴别.24例患者均行手术治疗随访6～96个月,平均随访(47.38±6.38)个月,复发3例(12.5％).结论 特发肉芽肿性乳腺炎多表现为可触及的乳腺肿块,影像学检查无特异性,最终需病理诊断,完整切除病变组织是其主要的治疗手段.     

Feasibility of surgical management in patients with granulomatous mastitis

Granulomatous mastitis (GM) is a rare inflammatory breast disease of unknown etiology. Although it usually presents with sinus formation and abscesses, it may mimic the clinical characteristics of breast cancer. The aim of this study was to identify the clinical, radiologic, and pathologic characteristics of patients with GM and to show the results of surgical treatment in these patients. A chart review was performed for patients that were treated with a diagnosis of GM at the Breast Unit, Department of Surgery, Istanbul Medical Faculty, University of Istanbul, between September 1998 and January 2003. Eighteen patients were eligible for this study. The median age was 41.5 years (range 16-80 years). Seventeen patients were evaluated by both ultrasonography and mammography; whereas one young patient only had ultrasonography. Three patients were further examined with color Doppler ultrasonography and magnetic resonance imaging (MRI). Fourteen patients (78%) presented with a mass as the chief symptom, with a median size of 3.9 cm (range 1-8 cm), whereas four patients presented with fistula in their breasts. None of the radiologic techniques distinguished benign disease from cancer in any of the 14 patients that presented with a mass except one patient with normal mammography findings. Ultrasonography was only helpful to localize the abscess associated with a fistula tract in one patient. Therefore fine-needle aspiration biopsy (FNAB) was performed in six patients, followed by surgical excisional biopsy. The remaining eight patients with a clinical suspicion of malignancy underwent wide surgical excision with frozen section analysis under general anesthesia. All of the FNAB and frozen section evaluations revealed benign findings. All of the 18 patients underwent a wide excisional biopsy and had a definitive histopathologic diagnosis of GM. The median follow-up was 36 months (range 6-60 months). Only one patient had a recurrent disease, which was diagnosed at 12 months. GM is a rare breast disease that mimics cancer in terms of clinical findings. Preoperative radiologic diagnosis might be difficult. Complete surgical excision is the treatment of choice.     

对比分析彩色多普勒超声诊断肉芽肿性乳腺炎与乳腺浸润性导管癌

目的对比分析肉芽肿性乳腺炎(GLM)与乳腺浸润性导管癌(IDC)的超声特点。方法回顾性分析经病理检查证实的26例GLM与28例IDC的超声检查结果,分析其声像图特征。结果 GLM病灶形态多不规则、边界不清晰、血流信号中等或较丰富,与IDC较相似。GLM病灶L/T值明显高于IDC,53.85%(14/26)的GLM病灶后方回声增强,而35.71%(10/28)IDC病灶后方回声衰减,且IDC患者PSV、阻力指数值及腋窝淋巴结肿大发生率均明显高于GLM。本组26例GLM中,术前超声仅诊断4例为炎症,28例IDC术前超声检查均诊断为恶性肿瘤。结论 GLM与IDC的声像学表现既有相似之处,同时亦各具特征,详细检查、综合分析有助于提高术前诊断的准确率。     

Lupus mastitis is not a surgical disease

A 23-year-old woman with a 2-year history of discoid lupus (SLE) presented with a right lateral upper quadrant breast mass. Physical examination revealed a 5 cm irregular, hard lesion suggestive of a breast malignancy. Ultrasound-guided fine needle aspiration biopsy of the mass confirmed the diagnosis as lupus mastitis. Differential diagnosis of a breast mass in a patient with SLE must include the possibility of lupus mastitis. Surgical resection is usually not necessary, and medical treatment can be implemented successfully.