Management of idiopathic granulomatous mastitis: dilemmas in diagnosis and treatment

BMC Surgery Management of idiopathic granulomatous mastitis: dilemmas in diagnosis and treatment Gulten Kiyak 0 3 Ersin Gurkan Dumlu 0 3 Ibrahim Kilinc 0 3 Mehmet Toka 0 3 Soner Akbaba 0 3 Ahmet Gurer 0 3 Alper Bilal Ozkardes 2 Mehmet Kilic 1 0 General Surgery Department, Ataturk Research and Training Hospital , 06800 Ankara , Turkey 1 Faculty of Medicine Department of General Surgery, Yildirim Beyazit University , Ankara , Turkey 2 Department of General Surgery, Yildirim Beyazit Research and Training Hospital , Ankara , Turkey 3 General Surgery Department, Ataturk Research and Training Hospital , 06800 Ankara , Turkey Background: Idiopathic granulomatous mastitis (IGM) is a rare inflammatory disease. Because of it's uncommon etiology and rareness, diagnosis and treatment is still a challenge. Owing to wide spectrum of IGM it is difficult to standardize and optimize the treatment. The aim of this study was to report and describe the clinical signs, radiological findings, management, clinical course and the recurrence rate of the patients which were treated due to IGM. Methods: In this retrospective review of patients diagnosed with IGM histopathologically between January 2006 and December 2011, medical reports, ultrasonography (US) and mammograhy (MMG) findings, follow-up information and recurrence were obtained from records. Results: Painful, firm and ill defined mass was the symptom of all patients. While parenchymal heterogeneity, abscess and mass were the findings of US, increased asymmetric density was the main finding of MMG. Wide local excision was performed in 15 (62.5%) patients, incisional biopsy with abscess drainage was performed in 9 (37.5%) patients. Median follow-up was 34.8 (range 10-66) months. Conclusions: While the physical examination give rise to thought of breast carcinoma, the appearance of parenchymal heterogeneity and abscess formation on US especially with enlarged axillary lymph nodes support the presence of an inflammatory process. But these findings do not exclude carcinoma. Hereby, histopathologic confirmation is mandatory to ensure that a malignancy is not missed. Beast; Granulomatous; Mastitis; Diagnosis; Treatment - Background IGM was first described by Kessler and Wolloch in 1972 [1]. IGM is a rare inflammatory disease of the breast, but it is important because of two reasons. First clinical and radiological findings of IGM mimicks breast carcinoma and the differential diagnosis can only be confirmed histopathologically. Second, it is difficult to treat IGM especially if presented with fistula and abscess formation. Because of its unclear etiology and rareness, diagnosis and treatment is still a challenge [2]. An optimal treatment has not been yet established, while medical therapy, wide local excision and abscess drainage are currently the favored treatment options for IGM [3]. The aim of this study was to report and describe the clinical signs, radiological findings, management, clinical course and the recurrence ratio of the patients which were treated due to IGM. Methods We reviewed records of patients diagnosed with IGM histopathologically between January 2006 and December 2011 in this retrospective study. The design of the study has been approved by Yildirim Beyazit University Faculty of Medicine ethics committee thus meets the standards of the Declaration of Helsinki. Due to retrospective nature of the study, the ethics committee did not require a written consent from the participants. Medical reports about the patients complaints, presence of pregnancy, number of pregnancies, use of contraceptives, follow-up informations and recurrence were obtained from clinical records. All of the patients underwent a clinical breast examination. An US was performed on all patients. A MMG was obtained from patients older than 40 years. A magnetic resonance imaging (MRI) was performed in one patient. Histopathological diagnosis was obtained from incisional or wide local excisional biopsies. Wide local excision was performed for a minimum lesion-free radial margin 510 mm. Incisional biopsy was obtained from patients with abscess formation. After drainage of abscess, incisional biopsy was performed from abscess cavity and obtained at least four tissue samples. If there was fistula formation to the skin, affected skin was excised too. Inflammatory reaction with granulomas which composed of epitheloid histiocytes, Langhans giant cells accompanied by lymphocytes, plasma cells and occasional eosinophils centered on lobules was diagnosed with IGM on histopathologic examination. All aspirates and tissue samples were examined with hematoxylin-eosin staining procedure as well as special stains for tuberculosis and fungal infection. Cultures for aerob bacteries (streptococcus, staphylococcus, enterococcus, klebsiella, pseudomonas, e. coli..), anaerob bacteries (clostridium, bacteroides..), were performed for the patients with abscess formation. US and physical examination were performed every month until resolution of lesions was confirmed. Results 24 patients diagnosed with IGM histopathologically and had complete follow-up data has been evaluated and included in the study. The mean age was 38.4 years ranged from 28 to 60 years. 87.5% of patients (n = 21) were at reproductive ages. All patients had children. None of the patients had a history of oral contraseptive use and lactacion in the last one year. Painful , firm and ill defined mass was the symptom of all patients. Painful mass lesions were accompanied with skin changes such as erythema and edema in 16 (66.6%) patients. The left breast was affected in 13 (54.1%) patients, right breast in 9 (37.5%) patients and bilateral in 2 (8.3%) patients. The lesions were located in upper external quadrant in 5 (20.8%) patients, in upper internal quadrant in 1 patient (4.2%) in inferior internal quadrant in 1 patient (4,2%), in inferior external quadrant in 3 (12.5%) patients, in periareolar region in 7 patients (29.2%) and diffuse involvement was seen in 7 patients (29.2%) (Table 1). Parenchymal heterogeneity with no discrete mass had been established in 7 patients (29.1%), irregular mass in 7 patients (29.1%), abscess formation in 4 patients (16.6%), irregular mass with heterogeneity in 1 patient (4.2%), heterogeneity with abscess formation in 4 patients (16.6%), heterogeneity, abscess formation and mass in 1 patient (4.2%) on US (Table 2) (Figure 1). Associated enlarged axillary lymph nodes were present in 14 (41.7%) patients. Table 1 Location of lesions in the breast Location of lesions in the breast MMG was obtained from 7 patients. MMG detected increased asymmetric density in 3 patients, asymmetric density with skin thickening in 2 patients and asymmetric density with skin thickening and nipple inversion in 2 patients. MRI was performed in one patient which involvement was diffuse and bilateral and resistant to the treatment (Figure 2). MRI was needed for this patient to obtain additional inf (...truncated)