Granulomatous Mastitis: Comparison of Novel Treatment of Steroid Injection and Current Management.

BACKGROUND: Granulomatous mastitis (GM) is a rare entity of benign origin. Multiple treatment strategies, including surgical procedures, can have sequelae of recurrence, nonhealing wounds, and protracted pain. Even after GM is diagnosed, the best management strategy remains controversial. We sought to evaluate intralesional steroid injection as a potential treatment for GM. MATERIALS AND METHODS: Electronic medical records from 2003 to 2017 of patients diagnosed with benign breast lesions were retrospectively reviewed. Patients with pathologically confirmed GM were identified. All treatment methods were documented, which included observation, oral steroids, methotrexate, steroid injection, and surgical excision. Primary outcome was time to resolution. Effectiveness was based on relief of symptoms along with duration of symptoms from initial time of diagnosis to full relief. Analysis of variance was used to compare outcomes between groups. RESULTS: Of the 49 patients with confirmed GM diagnoses, 57% had observation only, 24% had steroid injection, and 19% had surgical resection. The average time to resolution differed significantly among the three groups (11.5 mo from the start of observation, 2.0 mo from the time of steroid injection, and 0.5 mo from the time of surgical excision, P < 0.001). CONCLUSIONS: Intralesional steroid injection is an effective treatment of GM. Selective management is appropriate for patients with GM, and surgical resection is not required for most patients.

Experience with a Nonopioid Protocol in Ambulatory Breast Surgery: Opioids are Rarely Necessary and Use is Surgeon-Dependent.

CONTEXT: Surgeons write 1.8% of all prescriptions and 9.8% of all opioid prescriptions. Even small doses prescribed for short-term use can lead to abuse; thus, surgeons are uniquely able to combat the opioid epidemic by changing prescribing practices. As part of a department wide quality improvement project, we initiated a nonopioid protocol for all patients undergoing ambulatory breast surgery. OBJECTIVE: To determine the feasibility of a nonopioid protocol for patients undergoing ambulatory breast surgery and to determine if patient-related factors contribute to surgeon adherence to a nonopioid protocol in ambulatory breast surgery. DESIGN: Retrospective chart review of a prospectively collected database, with χ2 analysis and a multiple logistic regression model with the surgeon as the random effect. MAIN OUTCOME MEASURE: Protocol adherence. RESULTS: A total of 180 patients, with a median age of 63 years (range = 18-95 years), were included. Of these, 127 (70.6%) did not receive opioids; in this group there were 2 hematomas (1.6%), and 3 patients required an opioid prescription (2.4%). Fifty-three (29.4%) were prescribed opioids against protocol; in this group, there was 1 hematoma (1.9%). The operating surgeon was the only variable independently correlated with protocol adherence (p < 0.0001). Age, race/ethnicity, surgery type, and history of long-term opioid use were not. CONCLUSION: Ambulatory breast surgery patients tolerated a nonopioid pain regimen well. Surgeons' decisions, rather than patient characteristics, primarily drove the choice of pain management in our study. We believe our protocol can be improved with stricter implementation and education, which must be balanced with practitioner independence.