granulomatous mastitis the lect.ppt

Granulomatous
Mastitis
HAMEDRASHAD
Professor of Surgery Banha University

Granulomatous Mastitis
• Granulomatous Mastitis (GM) is first described by Kessler &
Wolloch in 1972,
• but Going and colleagues in 1987 recommended the term
“Granulomatous lobular mastitis (GLM)" to be used as being
more specific.
• In 2012, Pereira and colleagues recommended the term
‘Idiopathic Granulomatous Lobular Mastitis (IGLM)” to be used
which is more descriptive.
• Kessler E, Wolloch Y. Granulomatous mastitis: a lesion clinically simulating carcinoma. Am J Clin Pathol 1972; 58: 642–646.
• Going JJ, Anderson TJ, Wilkinson S, Chetty U Granulomatous lobular mastitis. J Clin Pathol 1987; 40:535–540
• Pereira FA, Mudgil AV,Macias ES, and Karsif K. Idiopathic granulomatous lobular mastitis. International Journal of Dermatology 2012, 51, 142–151

• IGLM is a benign chronic inflammatory
condition of the breast of unknown etiology
• characterized by non-caseating granulomas with
micro-abscess formation confined to the breast
lobules.
• It is mostly seen in females of childbearing age
within 5 years of last pregnancy and associated
breast feeding.
Idiopathic Granulomatous Lobular Mastitis
(IGLM)

Diagnosis of
Idiopathic Granulomatous Lobular Mastitis (IGLM)
• Pain, breast mass(s), subcutaneous
collection and sinus formation are
usually the first manifestations.
• Skin changes (erythema, edema,
ulceration and sinuses) were reported in
66% of patients.

Diagnosis of
• Diffuse involvement of the breast was seen
in 30% of patients.
• Upon resolution, common sequelae are
scarring & skin retraction.
• Nzegwu MA, Agu KA, Amaraegbulam PI. Idiopathic granulomatous mastitis lesion mimicking
inflammatory breast cancer. CMAJ 2007; 176: 1822.
• Kiyak G, Dumlu EG, Kilinc I et al. Management of idiopathic granulomatous mastitis: dilemmas
in diagnosis and treatment. BMC Surgery 14(4), 66 (2014).
dr_omarfarouk@yahoo.com

• No pathognomonic mammographic
features for IGLM
• but, parenchymal heterogeneity with a
focal asymmetrical density
corresponding to the palpable mass,
architectural distortion and irregular
‘masses’ or ‘nodules’ are common
abnormalities.
• Hovanessian Larsen LJ, Peyvandi B, Klipfel N et al. Granulomatous lobular mastitis:
imaging, diagnosis and treatment. Am. J. Rad. 2009; 193(2): 574-581
• Omranipour R, Mohammadi SF, Samimi P et al. Idiopathic granulomatous lobular
mastitis – report of 43 cases from Iran. Introducing a preliminary clinical practice
guideline. Breast Care 8(6), 439–443 (2013).
Diagnosis of

• Ultrasound examination reveals a
heterogeneous irregular hypoechoic mass
lesions in more than 80% of Cases.
• Tubular hypoechoic configuration areas
with finger-like structures connecting to the
mass occur in 50% of cases.
• Hovanessian Larsen LJ, Peyvandi B, Klipfel N et al. Granulomatous lobular mastitis: imaging,
diagnosis and treatment. Am. J. Rad. 2009; 193(2): 574-581
• Dursun M, Yilmaz S, Yahyayev A et al. Multimodality imaging features of idiopathic
granulomatous mastitis: outcome of 12 years of experience. Radiol. Med. 2012 117(4), 529–
538
Diagnosis of
Idiopathic Granulomatous Lobular Mastitis
(IGLM)

• In the absence of a mass lesion;
• US evidence of
– areas of mixed echopattern with
parenchymal deformity,
– multiple collection pockets & tracks,
– focal mastitis with interstitial edema,
• may indicate the presence of an inflammatory
granulomatous process.
• Kok KY, Telisinghe PU. Granulomatous mastitis: presentation, treatment and outcome in 43
patients. Surgeon 2010; 8:197-201.
• Lee JH, Oh KK, Kim EK, Kwack KS, Jung WH, Lee HK. Radiologic and clinical features of
idiopathic granulomatous lobular mastitis mimicking advanced breast cancer. Yonsei Med J 2006;
47:78-84.
Diagnosis of

• MRI has no current role in the routine
evaluation of suspected IGLM
• Ozturk M, Mavili E, Kahriman G et al. Granulomatous mastitis: radiological
findings. Acta Radiol. 48(2), 150–1552 (2007).
• Dursun M, Yilmaz S, Yahyayev A et al. Multimodality imaging features of
idiopathic granulomatous mastitis: outcome of 12 years of experience. Radiol. Med.
2012; 117(4), 529–538
Diagnosis of

• Both clinical and radiological findings are
not sufficient for diagnosis of IGLM as
they are not disease specific.
• Therefore, histopathological examination
via Core Needle Biopsy (CNB) plays a
very important role in Diagnosis of IGLM
• Akbulut S, Yilmaz D, Bakir S. Methotrexate in the Management of Idiopathic
Granulomatous Mastitis: Review of 108 Published Cases and Report of Four Cases. The
Breast Journal, 2011 Volume 17 Number 6, 661–668
• Gurleyik G, Aktekin A, Aker1 F, Karagulle H, Saglam A. Medical and Surgical Treatment
of Idiopathic Granulomatous Lobular Mastitis: A Benign Inflammatory Disease Mimicking
Invasive Carcinoma. J Breast Cancer 2012 March; 15(1): 119-123
dr_omarfarouk@yahoo.c
om
Diagnosis of

• The major histopathologic change is
lobulo-centric non-caseating inflammatory
granulomas.
• Granulomas composed of epitheloid
histiocytes, Langhans giant cells
accompanied by lymphocytes, and plasma
cells are generally found within and around
dilated lobules.
• Microabscess formation is commonly
observed
• Gurleyik G, Aktekin A, Aker1 F, Karagulle H, Saglam A. Medical and Surgical
Treatment of Idiopathic Granulomatous Lobular Mastitis: A Benign Inflammatory
Disease Mimicking Invasive Carcinoma. J Breast Cancer 2012 March; 15(1): 119-123
Diagnosis of

• An inflammatory reaction & localized
granulomatous response are triggered by
presence of extravasated secretions and milk
protein within the interstitial breast tissues
resulted from rupture of breast lobules as a
consequence of micro-trauma from breast
feeding or milk stasis due to obstruction caused
by local irritants or undetected infective
microorganisms.
Etiology & Pathogenesis of

• Milk stasis plays a key role with breast
tissue developing into a hypertrophic and
fragile state consequent to pregnancy,
lactation, hyperprolactinemia.
• Omranipour R, Mohammadi SF, Samimi P et al. Idiopathic granulomatous lobular mastitis – report of 43 cases
from Iran. Introducing a preliminary clinical practice guideline. Breast Care 8(6), 439–443 (2013).
• Al-Khaffaf B, Knox F, Bundred NJ. Idiopathic granulomatous mastitis: a 25-year experience. J Am Coll Surg
2008; 206:269-73.
• Ocal K, Dag A, Turkmenoglu O, Kara T, Seyit H, Konca K. Granulomatous mastitis: clinical, pathological
features, and management. Breast J 2010; 16:176-82.
• Diesing D, Axt-Fliedner R, Hornung D, et al. Granulomatous mastitis. Arch Gynecol Obstet 2004; 269: 233–236.

• Some authors claimed autoimmunity to be underlying the
etiology of IGLM which may represent a localized
autoimmune or hypersensitivity response,
• However, cases with a co-morbid autoimmune disorder
constitute only a minor fraction of all cases.
• Moreover, serologic marker tests of autoimmune disease (e.g.
antinuclear antibody and rheumatoid factor) are usually
negative.
• Gurleyik G, Aktekin A, Aker1 F, Karagulle H, Saglam A. Medical and Surgical Treatment of Idiopathic Granulomatous Lobular Mastitis: A Benign
Inflammatory Disease Mimicking Invasive Carcinoma. J Breast Cancer 2012 March; 15(1): 119-123
• De Hertogh DA, Rossof AH, Harris AA, Economou SG, et al. Prednisone management of granulomatous mastitis. N Engl J Med. 1980;
303(14):799–800.
• Erozgen F, Ersoy YE, Akaydin M, Memmi N, Celik AS, Celebi F, Guzey D, Kaplan R.. Corticosteroid treatment and timing of surgery in idiopathic
granulomatous mastitis confusing with breast carcinoma. Breast Cancer Res Treat 2010; 123:447-52.

• Corynebacteria have been identified in some
patients with IGLM.
• Taylor and colleagues in 2003 conducted a
study of 62 patients who were histologically
diagnosed with IGLM, and detected
Corynebacterium in 34 patients (54.8%);
• Taylor GB, Paviour SD, Musaad S, et al. A clinicopathological review of 34 cases of inflammatory
breast disease showing an association between corynebacteria infection and granulomatous mastitis.
Pathology 2003; 35: 109–119.
om

• There is no consensus on the optimal
treatment of IGLM
• Also, there are no randomized controlled
trials demonstrating the efficacy of any
treatment modalities up till now
• Benson JR , Dumitru D. Idiopathic granulomatous mastitis: presentation, investigation and
management Future Oncology Posted online on April 12, 2016. (doi:10.2217/fon-2015-0038)
om
Treatment of

1. Observation:
• Spontaneous resolution of IGLM lesions may
occur in 50% of patients without any treatment
within 2 years
• It is suitable only for smaller, unifocal lesion
with mild symptoms.
• Hur SM, Cho DH, Lee SK et al. Experience of treatment of patients with granulomatous lobular mastitis.
J. Korean Surg. Soc. 2013 85(1), 1-6.
• Benson JR , Dumitru D. Idiopathic granulomatous mastitis: presentation, investigation and management
Future Oncology Posted online on April 12, 2016. (doi:10.2217/fon-2015-0038)
• Lai EC, Chan WC, Ma TK, et al. The role of conservative treatment in idiopathic granulomatous
mastitis. Breast J 2005; 11: 454–456.
• Al-Khaffaf B, Knox F, Bundred N. Idiopathic granulomatous mastitis: a 25 year experience. J. Am. Coll.
Surg. 206(2), 269–273 (2008).
• Gurleyik G, Aktekin A, Aker F et al. Medical and surgical treatment of idiopathic granulomatous lobular
mastitis: a benign inflammatory disease mimicking invasive carcinoma. J. Breast Cancer 2012; 15, 119–
123
om
Treatment of

2. Antibiotics:
• There is a limited role for antibiotics in
management of IGLM.
• It should be guided by results of
microbiological culture, where there is 2ry
infection.
• Kok KY, Telsinghe PU. Granulomatous mastitis: presentation, treatment and outcome in 43
patients. Surgeon 8(4), 197–201 (2010).
• Benson JR , Dumitru D. Idiopathic granulomatous mastitis: presentation, investigation and
management Future Oncology Posted online on April 12, 2016. (doi:10.2217/fon-2015-0038)
Treatment of

3. Surgery:
• Wide local surgical excision is ideally suitable to
localized, uncomplicated discrete mass
• Clear margin is mandatory to avoid unnecessary
mastectomy and the need for subsequent therapies.
• but recurrence rates ranging from 5 to 50%.
• Bani-Hani KE, Yaghan RJ, Matalka, II, Shatnawi NJ. Idiopathic granulomatous mastitis: time to avoid
unnecessary mastectomies. Breast J 2004; 10:318-22.
• Kok KY, Telisinghe PU. Granulomatous mastitis: presentation, treatment and outcome in 43 patients.
Surgeon 2010; 8:197-201.
• Erozgen F, Ersoy YE, Akaydin M, Memmi N, Celik AS, Celebi F, Guzey D, Kaplan R.. Corticosteroid
treatment and timing of surgery in idiopathic granulomatous mastitis confusing with breast carcinoma.
Breast Cancer Res Treat 2010; 123:447-52.
• Taghizadeh R, Shelley OP, Chew BK, et al. Idiopathic granulomatous mastitis: surgery, treatment, and
reconstruction. Breast J 2007; 13: 509–513.
Treatment of

3. Surgery:
• Repeated surgical interventions lead to poor
cosmetic results and even massive contour
deformities and repeated abscesses development
in many cases.
• SSM and immediate breast reconstruction with
autogenous flaps may be a suitable alternative
surgical choice for diffuse or multifocal IGLM,
• Bani-Hani KE, Yaghan RJ, Matalka, II, Shatnawi NJ. Idiopathic granulomatous mastitis: time to
avoid unnecessary mastectomies. Breast J 2004; 10:318-22.
• Kok KY, Telisinghe PU. Granulomatous mastitis: presentation, treatment and outcome in 43
patients. Surgeon 2010; 8:197-201.
• Erozgen F, Ersoy YE, Akaydin M, Memmi N, Celik AS, Celebi F, Guzey D, Kaplan R..
Corticosteroid treatment and timing of surgery in idiopathic granulomatous mastitis confusing with
breast carcinoma. Breast Cancer Res Treat 2010; 123:447-52.
• Taghizadeh R, Shelley OP, Chew BK, et al. Idiopathic granulomatous mastitis: surgery, treatment,
and reconstruction. Breast J 2007; 13: 509–513.
Treatment of

4. Systemic Corticosteroids:
• Both dose and duration were widely different in
literature.
• 30 mg/day dose is effective.
• courses of 3–6 months duration are optimal to prevent
recurrence.
• the recurrent rate after systemic corticosteroids has been
reported as 15-50%.
• Sakurai K, Fujisaki S, Enomoto K et al. Evaluation of follow up strategies for corticosteroid therapy of idiopathic
granulomatous mastitis. Surg. Today 2011; 41(3):333-337
• Goldberg J, Baute L, Storey L et al. Granulomatous mastitis in pregnancy. Obstet. Gynaecol. 96(5), 813–815
(2000).
Treatment of

4. Systemic Corticosteroids:
• It should be administered after surgery in cases of
complicated, resistant cases, and when surgical
margins are ‘dirty’ with the aim of reducing
recurrence rates.
• it could be used before surgery in large
unresectable lesions and/or more diffuse lesions
to be ‘down staged’ and become more localized
and amenable to successful surgical excision.
• Akbulut S, Yilmaz D, Bakir S. Methotrexate in the Management of Idiopathic Granulomatous Mastitis:
Review of 108 Published Cases and Report of Four Cases. The Breast Journal, 2011 Volume 17 Number 6,
661–668
Treatment of

5. Methotrexate:
• an immunosuppressant which could modulate
the inflammatory process in IGLM without the
common sequelae of corticosteroids therapy.
• Dose; 10–15 mg weekly for 3–6 months
• It is indicated for resistant cases to maximal
doses of corticosteroids or fail to respond to a
second cycle of corticosteroids.
• Kim J, Tymms KE, Buckingham JM. Methotrexate in the management of granulomatous mastitis. ANZ
J. Surg.2003; 73(4), 247-249
• Raj N, Macmillan RD, Ellis IO, Deighton CM. Rheumatologists and breasts: immunosuppressive
therapy for granulomatous mastitis. Rheumatology (Oxford) 43(8), 1055–1056 (2004).
Treatment of

5. Steroids combined with prolactin inhibitors:
• Elevated prolactin levels have been identified in patients
with recurrent IGLM, although this association has not been
consistently observed.
• In one of the largest IGLM series to date including 206
patients, Aghajanzadeh and colleagues from Iran reported
treatment of 16 patients (resistant to steroid and
Methotrexate therapies), using a combination of steroid and
a bromocryptine (at a dosage of 5–10 mg daily) with a
positive response in five patients (31%).
• Aghajanzadeh M, Hassanzadeh R, Sefat SA et al. Granulomatous mastitis: presentation, diagnosis, treatment and
outcome in 206 patients from the north of Iran. Breast 2015; 24(4),456-460.
• Lee JH, Oh KK, Kim EK et al. Radiologic and clinical features of idiopathic granulomatous lobular mastitis mimicking
advanced breast cancer. Yonsei Med. J. 2006;47(1),78-84.
• Bani-Hani KE, Yaghan RJ, Matalka II et al. Idiopathic granulomatous mastitis: time to avoid unnecessary mastectomies.
Breast J. 10(4), 318–322 (2004).
om
Treatment of

6. Rifampicin:
• Our recent prospective study including 30 patients
with IGLM has successfully proven the efficacy of a
Rifampicin therapy regimen of 300 mg twice daily
for a period of 6–9 months in the treatment of IGLM
with complete clinical and ultrasonographic
response
• without any recurrent episodes after a median
follow-up of 15.5 months (average 3–35 months)
• it could be used as a solo medical therapy alternative
to both surgery and corticosteroids.
• Farouk O, Abdelkhalek M, Abdallah A, Shata A, Senbel A, Attia E, Elghaffar MA, Mesbah M, Soliman
N, Amin M, El-Tantawy D. Rifampicin for Idiopathic Granulomatous Lobular Mastitis: A Promising
Alternative for Treatment. World J Surg. 2017;41(5):1313-1321.
om
Treatment of

(A) IGLM patient aged 29 years; presented
with multiple masses, erythematous skin
patches, sinuses and subcutaneous
collection in the left breast.
(B) After 3 months of starting rifampicin
therapy; the inflammation and
subcutaneous collection had decreased, and
the sinus orifices and skin erosions had
healed.
(C) After 6 months of starting rifampicin
therapy; complete resolution of the
inflammation with healed sinus orifices and
some residual erythematous skin patches
were observed.
(D) After 9 months of starting rifampicin
therapy; complete clinical response to
treatment with some hyperpigmented scars.
Results of Rifampicin Therapy
Treatment of

with large breast mass measuring 14X12 cm
with multiple large erythematous skin
patches, sinuses in the right breast.
(B) After 3 months of starting of
rifampicin therapy; marked decrease in size
of mass, decrease in number & size of skin
sinuses & erythematous skin patches.
(C) After 6 months of starting Rifampicin
inflammation, disappearance of mass with
marked decrease in number & size of skin
sinuses & erythematous skin patches with
healed sinus orifices
inflammation with healed sinus orifices and
some residual erythematous skin patches
were observed.
Treatment of

om
with multiple masses, erythematous skin
patches and subcutaneous collection in the
right breast.
(B) After 3 months; the inflammation still
presented and some subcutaneous collection
had decreased, some sinus orifices and skin
erosions had healed with some areas
hypopigmentation.
(C) After 6 months; complete resolution of
the inflammation with healed sinus orifices
and hyporpigmented skin areas were
observed.
(D) After 9; complete clinical response to
treatment with decreased hyporpigmented
skin areas.
(E) After 12 months of stopping rifampicin
therapy (treatment for 9 months); she is
pregnant at 4 months with no recurrence and
no deformity.

(A) IGLM patient aged 23 years;
presented with multiple masses,
multiple erythematous skin
patches, sinuses and subcutaneous
collection in the right breast.
(B) After 6 months of starting of
rifampicin therapy; complete
resolution of the inflammation
with healed sinus orifices and
residual erythematous skin patches
were observed.
(C) After 9 months of starting
rifampicin therapy; complete
clinical response to treatment.
Treatment of

U.S. follow-up of Rifampicin therapy in a
patient with IGLM in the right breast;
(A) ill-defined irregular hypoechoic mass
(collection) measuring about 4.5 X3 cm in
diameter
(B) with massive interstitial edema and
collection pockets & tracks were observed
at the first time of presentation.
(C) After 6 months of starting rifampicin
therapy; irregular hypoechoic collection
measuring 2 cm with minimal edema in the
surrounding breast parenchyma.
therapy; normal ultrasound examination.
om
Treatment of

om
 Idiopathic Granulomatous Lobular Mastitis (IGLM) is a
rare chronic inflammatory breast disease, mimic
carcinoma.
 Milk stasis plays a key role in pathogenesis
 ‘Milk-induced autoimmune’ mechanism may be
modulated by presence of Corynebacteria infection.
Conclusion

om
 The self-limiting nature emphasizes the need to tailor treatments
according to the disease severity.
 Management remains controversial with multiple choices
including observation, surgery, systemic corticosteroids,
Bromocryptine and Methotrexate.
 Rifampicin is effective in treatment and could be an alternative to
both surgical resection and systemic corticosteroid therapy.
Conclusion

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