Presentation and Management of Granulomatous Mastitis in the United States: Results of an American Society of Breast Surgeons Registry Study.

BACKGROUND: Granulomatous mastitis (GM) is a benign, chronic, inflammatory disease lacking clear treatment guidelines. The purpose of this American Society of Breast Surgeons (ASBrS) prospective, multisite registry was to characterize the presentation of GM and identify treatment strategies associated with symptom resolution and optimal cosmesis. METHODS: ASBrS members entered data into a registry on patient demographics, treatment, symptoms, and cosmesis over a 1-year period. Initial symptoms were graded as mild, moderate, or severe. The Chi-square test and logistic regression were used to identify factors related to symptom improvement and cosmesis. RESULTS: Overall, 112 patients with a mean age of 36 years were included. More patients were Hispanic (49.1%) and from the Southwest (41.1%), and management included observation (4.5%), medical (70.5%), surgical (5.4%), or combination treatment (19.6%). Immunosuppression was used in 83 patients (74.1%), including 43 patients who received intralesional steroid injections. Patients with severe symptoms were more likely to undergo surgical intervention compared with those with mild or moderate symptoms (21.4% vs. 0% and 7.5%, respectively; p = 0.004). Within 1 year, 85 patients (75.9%) experienced symptom improvement and/or resolution at a median of 3 months. Receipt of immunosuppressive therapy was predictive of improvement or resolution at 1 month (odds ratio 4.22; p = 0.045). One-year physician-assessed cosmesis was excellent or good for 20/35 patients (57.1%) and was not associated with type of treatment or symptom severity. CONCLUSION: Although GM can have a protracted course, the majority of patients in this registry resolved within 1 year, with good cosmetic result. Treatment with immunosuppression appears to be most beneficial, and a symptom-based algorithm may be helpful to guide treatment.

Lactation Education for Surgeons: American Society of Breast Surgeons (ASBrS) Survey Demonstrates Strong Member Interest in Expanded Training.

BACKGROUND: The availability and extent of breastfeeding-specific surgical training has not been previously described. We aimed to survey breast surgeons on their lactation education and desire for additional knowledge. METHODS: Members of the American Society of Breast Surgeons were invited via email to anonymously complete an electronic survey from 27 October 2021 to 23 January 2022. The survey content included demographic information, sources of lactation education, and desired topics and methods for further training. Descriptive statistics were used to analyze the data. RESULTS: A total of 2698 surveys were delivered and 542 (20.1%) completed. While nearly all respondents (99%) reported treating lactating patients at least once or twice per year, 78% reported that their training was inadequate. The most frequently cited sources of lactation information were peer-to-peer informal knowledge sharing (50%) and personal experience with breastfeeding (44%). Nearly all respondents (99%) agreed that formal lactation education would benefit breast surgeons. Specific topics of interest included management of patients with complications of lactation (48%), management of lactating patients with a new diagnosis of breast cancer (47%), and counseling patients with pregnancy-associated breast cancer who desire to breastfeed (46%). The most frequently recommended educational formats included presentation at a national conference (60%), evidence-based management guidelines (58%), webinar (55%), and workshop/course (47%). CONCLUSION: Breast surgeons self-report minimal formal training in the management of benign and malignant breast disease in lactating patients and strong desire for expanded education. Development of clinical practice guidelines and additional educational content for surgeons should be considered to meet the needs of this patient population.

Breast Pathology That Contributes to Dysfunction of Human Lactation: a Spotlight on Nipple Blebs.

Nipple blebs are blister-like fibrinous lesions that form on the surface of the nipple during lactation, and can result in orifice obstruction and mastitis. They likely result from superficial extension of underlying ductal plugging, and can present concurrently with hyperlactation and mammary dysbiosis. Despite their prevalence, few formal reports on nipple blebs exist. In this perspective, we review the experience of a breastfeeding medicine practice that receives referrals for patients with nipple blebs, and provide preliminary insight into etiology, management, and outcomes of these lesions.

Lactational phlegmon: A distinct clinical entity affecting breastfeeding women within the mastitis-abscess spectrum.

We aimed to describe the presentation and treatment of lactational phlegmon, a unique complication of mastitis in breastfeeding women that may require surgical management. We retrospectively analyzed medical charts of breastfeeding women treated by a single breast surgeon for lactational phlegmon or the related conditions of abscess or uncomplicated mastitis (UM) from July 2016 to October 2018. Demographic variables and treatment details were analyzed using ANOVA and Pearson's Chi-square test. Ten women with lactational phlegmon (19.2%), 15 women with abscess (28.8%), and 27 women with UM (51.9%) were identified. Phlegmon presented as a tender, erythematous, and nonfluctuant mass in a ductal distribution. Ultrasonography demonstrated an ill-defined, complex fluid collection. Epidemiologically, women with phlegmon were similar to patients with abscess and UM. Women with phlegmon reported more intense deep breast massage than patients in the other two groups, but significantly lower rates of breast pump use than women with abscess (30.0% vs 80.0%, P < .05). Relative to women with UM, patients with complicated mastitis (CM, defined as phlegmon or abscess) reported greater utilization of nipple shields (36.0% vs 11.1%, P < .05). Treatment of phlegmon entailed effective milk removal, antibiotics (range 10-30 days), and close follow-up until both clinical and radiographic resolution (range 8 days to >3 months), with biopsy of persistent masses. Antibiotic duration was significantly longer for patients with phlegmon compared to those with UM (mean 15.0 days vs 9.7 days, P < .05). Two phlegmons coalesced into abscesses within 1 week of diagnosis. Lactational phlegmon is a complication of mastitis in breastfeeding women that is distinct from abscess and UM. Optimal treatment consists of an extended course of antibiotics and close follow-up to monitor for coalescence into a drainable fluid collection and/or persistence of mass requiring biopsy.

Breastfeeding and Breast Cancer: Managing Lactation in Survivors and Women with a New Diagnosis.

BACKGROUND: Supporting breastfeeding is a global health priority, yet few clinical guidelines exist to guide surgical oncologists in managing lactation during or after breast cancer treatment. METHODS: The literature was reviewed to identify evidence-based strategies for managing lactation during multidisciplinary breast cancer treatment or among breast cancer survivors. RESULTS: The majority of the evidence is from observational studies, with some higher levels of evidence, including systematic reviews and meta-analyses. Several significant gaps in knowledge remain. CONCLUSIONS: This review serves as a comprehensive resource of evidence-based recommendations for managing lactation in breast cancer survivors and breastfeeding women with a new breast cancer diagnosis.

Risk Factors, Symptoms, and Treatment of Lactational Mastitis.

This JAMA Insights Clinical Update reviews the risk factors for and symptoms of lactational mastitis and provides a potential treatment algorithm.

DCIS and axillary nodal evaluation: compliance with national guidelines.

BACKGROUND: The National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) provide guidelines regarding axillary nodal evaluation in ductal carcinoma in situ (DCIS), but data regarding national compliance with these guidelines remains incomplete. METHODS: We conducted a retrospective review of the National Cancer Data Base (NCDB) analyzing all surgical approaches to axillary evaluation in patients with DCIS. Logistic regression analysis was used to assess the multivariate relationship between patient demographics, clinical characteristics, and probability of axillary evaluation. RESULTS: We identified 88,083 patients diagnosed with DCIS between 1998 and 2011; 31,912 (37%) underwent total mastectomy (TM) and 55,349 (63%) had breast conserving therapy (BCT). Axillary evaluation increased from 44.4% in 1998 to 63.3% in 2011. In TM patients, axillary evaluation increased from 74.3% in 1998 to 93.4% in 2011. This correlated with an increase in sentinel lymph node biopsy (SLNB) from 24.3 to 77.1%, while ALND decreased from 50.0 to 16.3% (p <0.01). In BCT patients, evaluation increased from 20.1 to 43.9%; SLNB increased from 7.2 to 39.4% and ALND decreased from 12.9 to 4.5%. Factors associated with axillary nodal evaluation in BCT patients included practice type and facility location. Among TM patients, use of axillary lymph node dissection (ALND) for axillary staging was associated with earlier year of diagnosis, black race, and older age, as well as community practice setting and practice location in the Southern US. CONCLUSIONS: Compliance with national guidelines regarding axillary evaluation in DCIS remains varied. Practice type and location-based differences suggest opportunities for education regarding the appropriate use of axillary nodal evaluation in patients with DCIS.

Ductal Carcinoma In Situ: Treatment Update and Current Trends.

Ductal carcinoma in situ (DCIS) traditionally has been managed through various combinations of surgery, radiation, and endocrine therapy. However, concern for under- or over-treatment of DCIS has led many surgeons to question historically standardized approaches and instead begin to tailor treatment based on individual prognostic indicators. Recent and ongoing clinical trials have investigated the potential for active surveillance in DCIS, the possibility of eliminating radiation therapy (RT), and ways in which adjuvant systemic therapy may be refined. This review will summarize the current trends in the treatment of DCIS, as well as highlight the most pertinent clinical trials that are shaping management today.

An unusual breast lesion: granular cell tumor of the breast with extensive chest wall invasion.

Granular cell tumors (GCT) are generally benign soft tissue tumors. When located in the breast, they may be misdiagnosed as more typical tumors, such as invasive ductal carcinoma, based on misleading clinical or radiologic features. GCTs are frequently found in the setting of a known malignancy. We report the case of a patient with a large infra-mammary fold GCT, the management of which required a multidisciplinary operative approach due to extensive chest wall invasion.

Bedsharing among breastfeeding physicians: Results of a nationwide survey.

INTRODUCTION: Bedsharing is common but advised against by the American Academy of Pediatrics. It is unknown if breastfeeding physicians bedshare more or less than the general population. OBJECTIVES: To determine the prevalence of bedsharing among physicians, their reasons for bedsharing or not, and whether bedsharing was associated with a longer duration of breastfeeding. METHODS: An online survey was adapted from surveys administered by the Centers for Disease Control and Prevention. The survey was administered to physicians and medical students who birthed children from October 2020 through August 2021. Respondents were asked to report on a singleton birth, and questions centered around sleep practices and breastfeeding. Survival analysis was used to examine the association between bedsharing and breastfeeding duration. RESULTS: Of 546 respondents with bedsharing data, 68% reported some history of bedsharing, and 77% were in specialties that involved caring for pregnant people and/or infants. Those who bedshared breastfed an average of four months longer than those who never bedshared (18.08 versus 14.08 months p<0.001). The adjusted risk of breastfeeding cessation was markedly lower for those who bedshared compared to those who did not (Hazard Ratio 0.57, 95% Confidence Interval 0.45, 0.71). The primary reason for bedsharing was to breastfeed (73%); the primary reason for not bedsharing was safety concerns (92%). Among those who bedshared (n = 373), 52% did not inform their child's healthcare provider. CONCLUSIONS: Bedsharing is common among our sample of mainly breastfeeding physicians, including those who care for pregnant people and/or infants. It is also associated with a longer duration of breastfeeding, which has implications for population health. Practicing bedsharing implies cognitive dissidence and may affect how physicians counsel about bedsharing. Additionally, lack of disclosure of bedsharing practices has implications for practical guidance about having open non-judgmental conversations and may be a missed opportunity to counsel on bedsharing safety.

The JNK and Hippo pathways control epithelial integrity and prevent tumor initiation by regulating an overlapping transcriptome.

Epithelial organs maintain their integrity and prevent tumor initiation by actively removing defective cells, such as those that have lost apicobasal polarity. Here, we identify how transcription factors of two key signaling pathways-Jun-N-terminal kinase (JNK) and Hippo-regulate epithelial integrity by controlling transcription of an overlapping set of target genes. Targeted DamID experiments reveal that, in proliferating cells of the Drosophila melanogaster eye, the AP-1 transcription factor Jun and the Hippo pathway transcription regulators Yorkie and Scalloped bind to a common suite of target genes that promote organ growth. In defective neoplastic cells, AP-1 transcription factors repress transcription of growth genes together with the C-terminal binding protein (CtBP) co-repressor. If gene repression by AP-1/CtBP fails, neoplastic tumor growth ensues, driven by Yorkie/Scalloped. Thus, AP-1/CtBP eliminates defective cells and prevents tumor initiation by acting in parallel to Yorkie/Scalloped to repress expression of a shared transcriptome. These findings shed new light on the maintenance of epithelial integrity and tumor suppression.

Nodding syndrome in northern Uganda: overview and community perspectives.

The increasing prevalence of nodding syndrome in northern Uganda has generated a wide range of speculations with respect to etiology and natural history of and best possible medical treatment for this mysterious seizure disorder. Despite in-depth investigations by the United States Centers for Disease Control and Prevention and the Ministry of Health in Uganda, no clear causal factors have emerged. At the same time, northern Uganda communities are voicing concern for their lack of knowledge about nodding syndrome. The purpose of this commentary is to summarize northern Uganda community perceptions of this syndrome. These reflections demonstrate the need for larger investigations into the impact of nodding syndrome and other seizure disorders on local communities both in northern Uganda and throughout the world, in particular rural areas of resource poor countries.

Surgical education at Weill Bugando Medical Centre: supplementing surgical training and investing in local health care providers.

Global surgery initiatives increasingly are focused on strengthening education and local health care systems to build surgical capacity. The goal of this education project was to support local health care providers in augmenting the surgical curriculum at a new medical school, thus promoting long-term local goals and involvement. Working with local surgeons, residents, and medical and assistant medical officer students, we identified the most common surgical conditions presenting to Weill Bugando Medical Centre in Mwanza, Tanzania, and the areas of greatest need in surgical education. We developed an 8-week teaching schedule for undergraduate students and an electronic database of clinical surgery topics. In addition, we started teaching basic surgical skills in the operating theatre, bridging to an official and recurring workshop through a supporting international surgery organization. The medical and assistant medical officer students reported increased satisfaction with their clinical surgery rotations and mastery of key educational subjects. The initiation of an Essential Surgical Skills workshop through the Canadian Network for International Surgery showed students had improved comfort with basic surgical techniques. Short-term surgical missions may appear to fill a void in the shortage of health care in the developing world. However, we conclude that global health resources are more appropriately used through projects giving ownership to local providers and promoting education as a foundation of development. This results in better coordination among local and visiting providers and greater impact on education and long-term growth of health care capacity.

Les initiatives internationales en ce qui concerne la chirurgie sont de plus en plus axées sur le renforcement des programmes de formation et des systèmes de soins de santé locaux pour consolider les capacités dans ce domaine. L'objectif de ce projet éducatif était d'aider les professionnels de la santé locaux à enrichir le programme de chirurgie d'une nouvelle faculté de médecine et de favoriser ainsi l'atteinte des objectifs et une meilleure participation à long terme à l'échelle locale. En travaillant avec des chirurgiens, des résidents, des étudiants en médecine et de futurs aides-médecins locaux, nous avons recensé les chirurgies les plus fréquentes au Centre médical Weill Bugando à Mwanza à la Tanzanie, et les domaines de la chirurgie où les besoins de formation sont les plus grands. Nous avons mis sur pied un calendrier d'enseignement échelonné sur 8 semaines pour les étudiants et une base de données électronique sur les différents types de chirurgie clinique. Nous avons également commencé à enseigner les techniques chirurgicales de base au bloc opératoire, en parallèle avec un atelier officiel récurrent, grâce au soutien d'une association internationale de chirurgie. Les étudiants en médecine et les futurs aides-médecins se sont dits plus satisfaits de leur stage de chirurgie clinique et de leur maîtrise des principaux enjeux didactiques. Le lancement d'un atelier sur les compétences chirurgicales de base, rendu possible grâce au Réseau canadien pour la chirurgie internationale, a montré que les étudiants se sentent plus à l'aise avec les techniques chirurgicales de base. Les missions chirurgicales de courte durée peuvent sembler combler une lacune dans les pays en développement où les soins de santé sont insuffisants. Toutefois, nous concluons que les ressources en santé internationale sont utilisées de manière plus appropriée dans le cadre de projets qui responsabilisent les fournisseurs de soins locaux et favorisent leur formation comme base du développement. Cela donne lieu à une meilleure coordination entre les professionnels locaux et les coopérants et exerce un impact plus grand sur la formation et la croissance des capacités en matière de soins de santé à long terme.

The Breast: Premalignant Organ or Functional Gland?

Increasingly, young women are undergoing bilateral mastectomies before the completion of childbearing. This procedure, when performed prematurely, precludes any future lactation. However, not breastfeeding increases maternal and child morbidity and mortality, and carries an overall U.S. financial cost of $18.5 billion per year. The emotional and physical consequences of bilateral mastectomy in this patient population should be more carefully considered, and any prophylactic surgery deferred until childbearing has been completed.

Management of Common Complications of Lactation: The Breast Surgeon's Role in Examining the Science and Debunking Old Myths.

Breast surgeons are well poised to promote evidence-based recommendations for lactation-related breast disorders and clarify existing misconceptions in traditional care. Surgeons can resolve lactational fluid collections and avoid milk fistula development during drainage and/or other procedures on the breast. Using principles of surgical wound management, they can provide effective care of nipple trauma. They can distinguish between inflammatory and infectious mastitis and promote delicate tissue handling to prevent breast injury and phlegmon. Finally, breast surgeons can debunk the myth of fungal infections occurring on the highly vascularized nipple and recognize common presentations of conditions such as dermatitis.

Challenges in the Management of Breast Conditions During Lactation.

The lactating breast can develop a wide range of conditions that require surgical management, from abscess drainage to the evaluation of nipple-areolar complex (NAC) lesions. In addition, both benign and malignant masses can present in the lactating population. Patients should undergo routine diagnostic workup including core needle biopsy if indicated. Ultrasound, mammogram, and magnetic resonance imaging (MRI) with gadolinium contrast are safe in lactation and do not require interruption of breastfeeding.

Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022.

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. The Academy of Breastfeeding Medicine recognizes that not all lactating individuals identify as women. Using gender-inclusive language, however, is not possible in all languages and all countries and for all readers. The position of the Academy of Breastfeeding Medicine (https://doi.org/10.1089/bfm.2021.29188.abm) is to interpret clinical protocols within the framework of inclusivity of all breastfeeding, chestfeeding, and human milk-feeding individuals.

Elective global surgery rotations for residents: a call for cooperation and consortium.

BACKGROUND: International elective experiences are becoming an increasingly important component of American general surgery education. In 2011, the Residency Review Committee (RRC) approved these electives for credit toward graduation requirements. Previous surveys of general surgery program directors have established strong interest in these electives but have not assessed the feasibility of creating a national and international database aimed at educational standardization. The present study was designed to gain in-depth information from program directors about features of existing international electives at their institution and to ascertain interest in national collaboration. METHODS: This cross-sectional study of 253 United States general surgery program directors was conducted using a web-based questionnaire program. RESULTS: Of the program directors who responded to the survey, twelve percent had a formal international elective in place at their institution, though 80% of these did not have a formal associated curriculum for the rotation. Sixty percent of respondents reported that informal international electives existed for their residents. The location, length, and characteristics of these electives varied widely. Sixty-eight percent of program directors would like to participate in a national and international database designed to facilitate standardization of electives and educational exchange. CONCLUSIONS: In a world of increasing globalization, international electives are more important than ever to the education of surgery residents. However, a need for standardization of these electives exists. The creation of an educational consortium and database of international electives could improve the academic value of these electives, as well as provide increased opportunities for twinning and bidirectional exchange.

Management of idiopathic granulomatous mastitis in lactation: case report and review of the literature.

BACKGROUND: Idiopathic Granulomatous Mastitis (IGM) is a benign chronic inflammatory breast condition that mimics two common breast disorders: breast carcinoma and breast abscess. It can form breast masses, fistulae, and fluid collections, resulting in breast disfigurement with retraction and nipple areolar complex (NAC) inversion. IGM most often presents in women of childbearing age within a few years of pregnancy, and can significantly impact lactation. Despite the prevalence of this disease, no current literature describes an approach to managing IGM during breastfeeding. CASE PRESENTATION: A 28-year-old G3P2 patient of Native American origin presented to her obstetrician at 7 months pregnant with worsening left breast swelling and redness. She underwent a mammogram, ultrasound and core needle biopsy that confirmed the diagnosis of Idiopathic Granulomatous Mastitis. During the postpartum period, she underwent intralesional triamcinolone injections of her left breast. Due to the contraindication of breastfeeding after local steroid injection, the patient stopped breastfeeding from the affected breast and continued breastfeeding unilaterally. CONCLUSIONS: Idiopathic Granulomatous Mastitis is a challenging chronic inflammatory breast disease that affects women primarily in the reproductive years, with a higher incidence in patients of Hispanic, Native American, Middle Eastern, and African descent. Treatment of IGM during pregnancy and lactation has thus far not been addressed. We review the literature on the treatment of IGM in the non-lactating population, and propose considerations for treating breastfeeding women affected by this disease. Traditional treatment has included systemic immunosuppression and surgery, but newer literature demonstrates that intralesional injection of steroid can provide significant symptomatic relief to patients. A diagnosis of IGM does not preclude breastfeeding, though patients may experience challenges with milk production and latch on the affected breast. Individualized care should be provided, with considerations given to the following: side effects of systemic steroids, the need to wean a breast being treated with intralesional steroids, and augmentation of milk production on the unaffected breast to promote continued breastfeeding.