Ultrasound-guided vacuum-assisted excision for idiopathic granulomatous mastitis at the abscess stage.

BACKGROUND: Idiopathic granulomatous mastitis (IGM) is a rare inflammatory disease of the breast with clinical features that are often confused with those of breast cancer leading to delayed diagnosis and treatment. This retrospective study aimed to evaluate the therapeutic effectiveness and cosmetic results of drainage surgery using ultrasound-guided vacuum-assisted excision (VAE) for the treatment of IGM at the abscess stage. METHODS: The time of recovery, cases of further surgical intervention, and cosmetic results were retrospectively collected and analyzed from patients who underwent drainage with VAE or conventional drainage between October 2017 and August 2021. RESULTS: A total of 65 patients diagnosed with IGM at the abscess stage who underwent drainage surgery with VAE or conventional drainage surgery were enrolled. Overall, 38 (58.5%) underwent conventional drainage surgery and 27 (41.5%) underwent drainage with VAE. We found that patients who underwent VAE recovered much faster than those who underwent traditional drainage surgery (30.1 vs. 48.0 days). Nine (33.3%) patients in the VAE group required further surgical intervention after drainage, whereas 33 (86.8%) patients in the control group underwent another surgery to resect residual lesions. Additionally, patients in the VAE group were more satisfied with the breast appearance, mainly due to less influence of the scars and better symmetry of their breasts. CONCLUSION: Compared with conventional drainage surgery, drainage surgery using VAE for IGM patients at the abscess stage improved therapeutic and cosmetic outcomes. Furthermore, postoperative management of IGM is crucial.

Mammography and Digital Breast Tomosynthesis in Granulomatous and Nongranulomatous Mastitis.

INTRODUCTION: Digital Mammography (DM) is extensively used for breast imaging however, lesion visibility is often limited by overlapping tissues, which affects lesion characterization. Digital breast tomosynthesis (DBT) reduces the effect of overlapping tissues and helps in revealing obscured findings. We aimed to describe the mammographic findings in granulomatous and non-granulomatous mastitis and assess the utility of adjunctive DBT in lesion characterization. MATERIALS AND METHODS: DM and DBT images of histo-pathologically diagnosed cases of granulomatous (GM) and non-granulomatous mastitis (NGM) were reviewed according to the BI-RADS lexicon. Presence of contiguous/ interconnected lesions, tubular densities, interspersed hypodensities/fat densities within the involved areas were also assessed. The perceived utility of adjunct DBT was scored from 0-2. RESULTS: Of 33 reviewed patients (24 GM, 9 NGM; median age 39 years, range 24-78); 13/33 (39.4%) were under 35 years of age. DBT detected masses in 24/33 (72.7%), whereas only 15/33 (45.4%) were visible on DM alone. Contiguous or inter-connected lesions were found in 10/33 (30.3%) cases. Tubular extensions were seen in 14 cases and interspersed hypodensities in 15. None of the enlarged lymph nodes had irregular shape or indistinct margins or loss of fatty hilum. DBT was able to categorize more lesions as BIRADS 4a or below, as compared to DM alone. CONCLUSIONS: Mammographic presence of multiple contiguous iso-dense masses, reniform contour of axillary lymph nodes with preserved fatty hilum despite a large area of breast involvement favour a benign etiology; especially if DBT reveals tubular extensions or lesions with inhomogenous low density areas within.

Idiopathic granulomatous mastitis: clinical, histopathological, and radiological characteristics and management approaches.

Idiopathic Granulomatous Mastitis (IGM) is an infrequent, benign breast disease that primarily affects women during their childbearing years and can be mistaken for breast cancer. This study aimed to review the clinical, radiological, and histopathological findings of patients with IGM in addition to management and outcome. Retrospective cross-sectional study of biopsy-confirmed IGM at an academic medical center and a private hospital in Amman, Jordan. Fifty-four patients were included, with a mean age of 37.0 ± 9.04 years, mostly presenting with a breast lump (n = 52, 96.3%) and breast pain (n = 45 patients, 84.9%). Approximately half of the patients (51.9%) were parous, and 50% had breastfed for an average duration of 30.37 ± 22.38 months. Most of the patients had either solitary or multiple abscesses on breast ultrasound. Histopathological analysis (n = 35) showed mostly either moderate inflammation (n = 16, 45.7%) or severe inflammation (n = 14, 40%). Two-thirds of the patients underwent surgical interventions at the time of diagnosis, mostly incision and drainage (n = 16, 29%) or surgical excision (n = 7, 13%), and no mastectomies were performed. The most common medical treatment included a combination of antibiotics, corticosteroids, and methotrexate (n = 21, 38.8%). After follow-up, 31 patients remained in remission, 3 experienced relapses, and 3 had a chronic course. The use of corticosteroids was significantly associated with remission (p = 0.035). The presentation and demographics of IGM patients in Jordan were consistent with the existing literature. Prospective research is needed to explore different treatment options and disease outcomes.

Does ARFI elastography complement B-mode ultrasonography in the radiological diagnosis of idiopathic granulomatous mastitis and invasive ductal carcinoma?

BACKGROUND: Idiopathic granulomatous mastitis (IGM) is a chronic, unpleasant autoimmune inflammatory condition and is clinically and radiologically often confused with breast malignancy. PURPOSE: To investigate the contributions of qualitative and quantitative aspects of acoustic radiation force impulse (ARFI) elastography to the differential diagnosis between IGM and invasive ductal carcinoma (IDC) in the breast. MATERIAL AND METHODS: Ninety-four women with IDC and 39 with IGM were included in the study. Shear wave velocity (SWV) was calculated for all lesions using quantitative elastography. Next, each lesion's correspondence on qualitative elastographic images to those on the B-mode images was evaluated: pattern 1, no findings on elastography images; pattern 2, lesions that were bright inside; pattern 3, lesions that contained both bright and dark areas; and pattern 4, lesions that were dark inside. Pattern 4 was subdivided into 4a (dark area same size as lesion) and 4b (dark area larger than lesion size). Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were calculated. RESULTS: The mean SWV based on ARFI elastography was 3.78 ± 1.26 m/s for IGM and 5.34 ± 1.43 m/s for IDC lesions (P < 0.05). Based on qualitative ARFI elastography, IDC lesions were mostly classified as pattern 4b, while IGM lesions were mostly classified as pattern 1 or 2 (P = 0.01). Evaluation of both the qualitative and quantitative aspects of ARFI elastography yielded a sensitivity of 89% and specificity of 84%. CONCLUSION: ARFI elastography may facilitate the differential diagnosis between IGM and IDC.

Treatment of idiopathic granulomatous mastitis using ultrasound-guided microwave ablation: a report of 50 cases.

OBJECTIVE: This study aimed to evaluate the efficacy and safety of ultrasound-guided microwave ablation combined with glucocorticoid therapy for treating idiopathic granulomatous mastitis (IGM). METHODS: From June 2017 to March 2020, 50 consecutive patients diagnosed with IGM using puncture histology were included. All patients received prednisone and ultrasound-guided microwave ablation and were closely monitored for 12-15 months. RESULTS: A total of 222 lesions in 50 patients were ablated. The results indicated that 78% of cases were cured within 12 months and an additional 20% were cured within 15 months; the recurrence rate was 2%. The clinical and pathological remission rate of the entire group was 98%. The main postoperative complications were local pain, skin ulcerations and sinus formation, skin and areola heat damage, subcutaneous congestion, and fat liquefaction, all of which were conservatively treated. CONCLUSION: Microwave ablation combined with glucocorticoid therapy was safe and effective for the treatment of IGM, with a low recurrence rate. In addition, the cosmetic appearance of the affected breast was preserved with little trauma. Therefore, microwave ablation is a viable method that can be successfully applied in clinical practice.

Idiopathic granulomatous mastitis: case series and clinical review.

Idiopathic granulomatous mastitis is a chronic inflammatory breast disorder that typically affects young, parous women, often following lactation. Patients present with tender, erythematous breast lesions with histological evidence of non-caseating granulomata and an inflammatory cell infiltrate. An immune-mediated pathophysiology is hypothesised and an association with lipophilic Corynebacterium species is observed. Initial diagnosis is often delayed due to lack of awareness of the condition and management of refractory disease can be challenging. We present an extensive case series of patients collaboratively managed by subspecialty physicians and surgeons at a single centre in Sydney, Australia. The accompanying review expands on features of this condition and supports the utility of a multidisciplinary approach.

You'll see it when you know it: granulomatous mastitis.

Granulomatous mastitis (GM) is an under-recognized and under-diagnosed disease. Patients with GM often present to the emergency room with a painful breast mass, nipple retraction, and skin changes. This pictorial essay will review the clinical presentation and imaging appearance of GM, BI-RADS reporting parameters, differential diagnoses, and diagnostic challenges posed by this disease. Early and accurate diagnosis is essential, as misdiagnosis can result in repeated core biopsies, leading to fistulae and sinus tract formation. A classic history and typical sonographic appearance allow the emergency radiologist to confidently make this diagnosis.

Granulomatous mastitis treatment options and our experience.

Granulomatous mastitis (GM) is a rare benign inflammatory disease of the breast, first described by Kessler and Wolloch in 1972. Clinically, it can present as unilateral, sometimes painful, increasing breast resistance, or as a hard, irregular mass. Sonography is the most useful diagnostic method for GM evaluation. The only method for definitive diagnosis is the use of biopsy. In histological findings, GM is characterized by non-caseifying granulomas, often associated with microabscess and fistula formation. There is considerable heterogeneity in treatment options; this may explain the high recurrence rate which is close to 50%. Such a high recurrence rate is alarming and proves that current treatments are suboptimal. Two treatment options are discussed worldwide: conservative strategies involving drug therapy with corticosteroids versus a surgical approach involving partial or total mastectomy. All conservative treatment options are associated with a high risk of recurrence, and most patients require surgery in the end. Thorough excision of inflammatory tissue is crucial for successful treatment while negative surgical margins are associated with a low recurrence rate. The surgical approach to GM requires sufficient radicality and presumes knowledge in the field of reconstructive breast surgery, similarly to oncosurgical breast conservation operations. However, alternatives to GM treatment with oral steroids may be acceptable for patients concerned about surgery. This article presents six case reports of patients treated at our department.

Ultrasound classification-guided minimally invasive rotary cutting in granulomatous lobular mastitis.

BACKGROUND: To summarize the clinical experience of ultrasound-guided minimally invasive surgery for granulomatous lobular mastitis (GLM), and explore the feasibility of this technique for treating GLM. METHODS: This retrospective study reviewed the clinical features and treatment outcome of 30 patients who were diagnosed pathologically as GLM from 2016.3 to 2019.5 in the Department of Breast Surgery, Women's and Children's Hospital, Xiamen University. These patients weretreated with ultrasound-guided Mammotome minimally invasive surgery, and we tried to classified the lesion into four distinct patterns (diffuse abscess mixed type, sheet hypoechoic type, localized abscess type, localized hypoechoic mass type) according to the sonographic findings and clinical symptoms to find out if these patterns correlated with treatment and recurrence rate. RESULTS: After a median follow-up of 12 months on average (4-42 months), 26 cases (86.7%) were cured without acute or chronic complications such as disseminated inflammation and bleeding. Post-operative bleeding occurred in 1 case, and 3 cases (10.00%) relapsed. The ultrasound classification had 0 cases of diffuse abscess mixed type, 17 cases (56.7%) of sheet hypoechoic type, 9 cases (30%) of localized abscess type, and 4 cases (13.3%) of localized hypoechoic mass type. All 3 recurrent cases were sheet hypoechoic type, which were cured after another open surgical resection and showed no recurrence during an average follow-up of 20 months (11-40 months). CONCLUSIONS: In treating GLM patients with minimally invasive rotary cutting, ultrasound classification helps to select suitable patients, especially those with localized abscess and localized hypoechoic mass types with low recurrence rate, which is one of the safe and effective treatment methods.

Idiopathic granulomatous mastitis: Management and predictors of recurrence in 474 patients.

Idiopathic Granulomatous Mastitis (IGM) is an uncommon inflammatory disease of the breast, with similar presentations as breast cancer and a relatively high recurrence rate. We reviewed the demographics, clinical presentations, and treatment modalities of a large cohort of patients in Iran. Most of the patients had history of pregnancy and breastfeeding. The most common clinical finding was pain and a palpable mass, respectively. Most of the patients received medical treatment, and about half of the patients had surgery. The recurrence rate was 24.8%, and breast skin lesions were associated with a significantly higher odds of recurrence.

Comparison of Topical, Systemic, and Combined Therapy with Steroids on Idiopathic Granulomatous Mastitis: A Prospective Randomized Study.

BACKGROUND: Idiopathic granulomatous mastitis (IGM) is a benign disorder of the breast, for which the optimal treatment modality remains missing. METHODS: A total of 124 patients with a histopathologically proven diagnosis of IGM were enrolled in a prospective, randomized parallel arm study. Patients were treated with topical steroids in Group T (n: 42), systemic steroids (0.8 mg/kg/day peroral) in Group S (n: 42), and combined steroids (0.4 mg/kg/day peroral + topical) in Group C (n: 40). Compliance with the therapy, response to the therapy, the duration of therapy, side effects and the recurrence rates were compared. RESULTS: Sixteen patients did not comply with the treatment, and the highest ratio of compliance with therapy was seen in Group T (p < 0.05). Complete clinical regression (CCR) was observed in 90 (83.3%) patients. Response to the treatment (RT) was evaluated radiologically and observed in 89.8% of the patients. There was no statistically significant difference between groups regarding CCR, RT and the recurrence rate. The longest duration of therapy was observed in Group T (22 ± 9.1-week), whereas the shortest was observed in Group S (11.7 ± 5.5-week) (p < 0.001). The systemic side effects were significantly lower in Group T in comparison with Groups S and C (2.4% vs. 38.2% and 30.3%, respectively) (p < 0.001). CONCLUSIONS: The efficiency of the treatment was similar for all groups, both clinically and radiologically. Although the duration of therapy was longer in Group T, the lack of systemic side effects increased the compliance of the patients with the therapy. Therefore, topical steroids would be among first-line treatment options of IGM.

Idiopathic Granulomatous Mastitis - a new approach in diagnostics and treatment.

Idiopathic granulomatous mastitis (IGM) is a rare inflammatory breast disease mimicking carcinoma and puerperal or non-puerperal mastitis. The primary purpose of this prospectively performed case control study was to compare clinical and imaging signs of IGM with the reference group of nonspecific, non- puerperal mastitis (NM) to identify the most typical clinical and imaging signs essential for a correct differential diagnosis. The secondary purpose was to present a new approach to non-invasive treatment. Thirty-nine women with histologically proven IGM and twenty-six patients with nonspecific mastitis underwent clinical examination, breast ultrasound (US), mammography (MG) and MRI examination. The most typical signs were selected for each group, and method and were statistically evaluated. The effectivity of colchicine, vitamin E and ribwort plantain tincture in treatment was assessed by clinical examination and imaging. Typical clinical signs of IGM included unilateral acute onset of breast edema, redness, palpable masses, missing fever, lymphadenopathy, no response to antibiotics or surgical interventions. Ultrasound revealed: "finger-like" structures (100%), ductectasias (76.9%), abscesses (76.9%), and lymphadenopathy (15.4%), while in MRI skin and tissue edema (100%), multicentric lesions (100%), abscesses (76.9%), ring enhancement (84.6%), lymphadenopathy (15.4%) and small enhancing lymph nodes (38.5%) were observed. Among the clinical signs, fistulas, hypoechoic mass, ductectasias and diffusion weighted images (DWI) restriction were significantly more frequent in patients with IGM than in those with NM. Treatment effectivity yielded 100% with a complete response between 6-19 months, depending on the disease extent. Targeted questions together with imaging can speed up selection for proper treatment with colchicine, vitamin E and local treatment. Long lasting use of antibiotics and repeated surgical interventions should be avoided.

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.

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.

Granulomatous mastitis: etiology, imaging, pathology, treatment, and clinical findings.

PURPOSE: To outline the demographics, clinical presentation, imaging features, and treatment modalities observed among a series of patients diagnosed with biopsy-proven granulomatous mastitis (GM). METHOD: Following approval by institutional review board, retrospective chart review was performed on patients with biopsy-proven granulomatous mastitis at our institution in the period from January 2013 until October 2017. RESULTS: A total of 90 patients were identified: 87 women and 3 men. The mean age was 35 years, mostly women in their reproductive age. In our study, patients with GM were more likely to be Hispanic compared to the general population. Sixty-three percent of patients were within 5 years of previous pregnancy. Painful palpable mass-like lesion was the most common physical finding. Breast ultrasound (US) was performed in all patients, and most commonly showed a hypoechoic irregular-shaped mass. Mammography (MG) showed asymmetry or irregular mass as the main finding. Definitive diagnosis was obtained by imaging-guided core needle biopsies in 94.4%. Conservative management was preferred, and only one patient underwent surgery. CONCLUSION: Although clinical and radiological findings of patients with GM may mimic those of breast carcinoma, our study showed that women of childbearing age, especially among Hispanic ethnicity with a recent history of pregnancy or high prolactin level and newly tender mass-like lesion, in addition to new focal asymmetry on mammogram and heterogeneous hypoechoic irregular-shaped mass on ultrasound exam, should raise concern for GM. Non-invasive approach and clinical follow-up were the preferred treatment method.

Diffusion-weighted imaging in relation to morphology on dynamic contrast enhancement MRI: the diagnostic value of characterizing non-puerperal mastitis.

OBJECTIVES: To demonstrate the value of diffusion-weighted imaging (DWI) in the characterisation of mastitis lesions. METHODS: Sixty-one non-puerperal patients with pathologically confirmed single benign mastitis lesions underwent preoperative examinations with conventional MRI and axial DWI. Patients were categorised into three groups: (1) periductal mastitis (PDM), (2) granulomatous lobular mastitis (GLM), and (3) infectious abscess (IAB). Apparent diffusion coefficient (ADC) values of each lesion were recorded. A one-way ANOVA with logistic analysis was performed to compare ADC values and other parameters. Discriminative abilities of DWI modalities were compared using the area under the receiver operating characteristic curve (AUC). P < 0.05 was considered statistically significant. RESULTS: ADC values differed significantly among the three groups (P = 0.003) as well as between PDM and IAB and between PDM and GLM. The distribution of non-mass enhancement on dynamic contrast-enhanced (DCE) MRI differed significantly among the three groups (P = 0.03) but not between any two groups specifically. There were no differences in lesion location, patient age, T2WI or DWI signal intensity, enhancement type, non-mass internal enhancement, or mass enhancement characteristics among the three groups. CONCLUSIONS: ADC values and the distribution of non-mass enhancement are valuable in classifying mastitis subtypes. KEY POINTS: • Mastitis subtypes exhibit different characteristics on DWI and DCE MRI. • ADC values are helpful in isolating PDM from other mastitis lesions. • Distribution of non-mass enhancement also has value in comparing mastitis subtypes.

Idiopathic Granulomatous Mastitis: Manifestations at Multimodality Imaging and Pitfalls.

Idiopathic granulomatous mastitis (IGM) is a rare benign inflammatory breast entity characterized by lobulocentric granulomas. IGM has a persistent or recurrent disease course and affects parous premenopausal women with a history of lactation. It has also been associated with hyperprolactinemia. The most common clinical sign is a palpable tender mass. However, the nonspecific manifestations and varied demographic features of this condition, as well as the other similar-appearing and superimposed breast entities, pose substantial diagnostic challenges. Entities with similar manifestations include inflammatory breast cancer (IBC), infective mastitis, foreign body injection granulomas, mammary duct ectasia, diabetic fibrous mastopathy, and systemic granulomatous processes. The strategy for imaging IGM depends on patient age, clinical manifestations, and risk factors. Targeted ultrasonography, mammography, and less commonly, magnetic resonance imaging have proven to be useful for imaging evaluation. Core-needle biopsy, with or without fine-needle aspiration for cytopathologic examination, and culture analysis are usually required to exclude IBC and other benign inflammatory breast processes. Patients with IGM have an excellent prognosis when they are appropriately treated with oral steroids or second-line immunosuppressive and prolactin-lowering medications. However, surgical excision may be an option for patients in whom medication therapy is unsuccessful. Imaging surveillance can be offered to patients with incidentally encountered IGM or mild symptoms. Clinical suspicion for this rare disease and the breast imager's prompt diagnosis can lead to an improved patient outcome. The purpose of this article is to review the imaging manifestations of IGM in a multimodality case-based format and to describe relevant clinical and imaging-based differential diagnoses. The associated pitfalls, epidemiologic and histopathologic factors, clinical manifestations, natural course, and management of IGM also are discussed. ©RSNA, 2018.

[Multi-variated analysis of differential diagnosis in ultrasonography of idiopathic granulomatous mastitis and invasive ductal carcinoma].

Objective: To evaluate the differential diagnosis of idiopathic granulomatous mastitis (IGM) and invasive ductal carcinoma. Methods: The ultrasonographic data of 37 IGM patients and 50 cases of IDC were analyzed retrospectively. The shape, growth direction, margin, internal echo, posterior echo, calcification, Adler blood flow classification, PSV(peak sestolic velocity), RI (resistance index)and elasticity scores were analyzed by χ(2) test and independent sample t test. The optimal cutoff values of age, PSV and RI were calculated by receiver operating characteristic (ROC) curve. Logistic regression analysis was used to calculate the odds ratio (OR) of ultrasonic variates in the diagnosis of both diseases. Results: There were no significant differences in the shape, margin, internal echo and blood flow grading between the two groups. The age, lesion growth direction, posterior echo, calcification, PSV, RI and elasticity were statistically different. The cut-of value of Age, PSV and RI were 38.5 years old, 13.20 cm/s, and 0.655. Logistic regression multi-variated analysis revealed that elastic score (OR=9.806) had the best value of the differential diagnosis, as well as calcification (OR=6.937), posterior echo decay (OR=4.613), RI (OR=3.257), lesion growth orientation (OR=3.198), and PSV (OR=1.202). Lesion shape, margin, internal echo, and Adler blood flow classification did not help in differential diagnosis. Conclusion: Ultrasound multi-parameter analysis has high value in IGM and IDC differential diagnosis.