Case Report: Ductal Carcinoma in Situ Within A Granulomatous Mastitis.

Objective To investigate the value of color Doppler ultrasonography in differential diagnosis of granulomatous lobular mastitis (GLM) and breast cancer. Methods Preoperative sonograms of 45 GLM, 115 invasive ductal carcinoma (IDC) and 90 ductal carcinoma in situ (DCIS) patients were retrospectively analyzed and further confirmed by histopathology. Results The average age of patients in GLM group was obviously younger than those in IDC and DCIS groups(P<0.001). The size of mass lesion in GLM group was significantly larger than those in IDC and DCIS groups(P<0.001). Compared to IDC group, GLM group showed higher detection rate of liquidity area and mammary ductal ectasia (P<0.01), while less lesions with irregular shape, large A/T ratios (≥0.7), calcification, spiculate margin, peripheral hyperechoic zone or posterior echo attenuation (P<0.05). There were more lesions with spiculate margin, liquidity area or axillary lymph node enlargement found in GLM group than in DCIS group (P<0.01), but less calcification (P<0.001). The accordance rate of ultrasonic diagnosis and postoperative histopathology results in 45 GLM patients was 33.3%(15/45). Conclusions GLM shows the characteristic sonographic findings. In addition, there are some differences between GLM and both IDC & DCIS, such as spiculate margin, peripheral hyperechoic zone, blood flow richness and axillary lymph node enlargement. Combined with the clinical data, understanding the sonographic features of GLM is beneficial to its differential diagnosis with breast cancer. Key words: Ultrasonography; Granulomatous mastitis; Diagnosis, differential

Background: Granulomatous lobular mastitis (GLM) is a rare inflammatory disease of the breast. Its clinical features and imaging findings often mimic malignancy. The aim of this study is to review the mammographic and ultrasound features of granulomatous lobular mastitis to help differentiate it from other diagnoses. Methods: In our study, imaging data of 51 patients were reviewed retrospectively, who were diagnosed with granulomatous lobular mastitis by core needle biopsy and culture analysis. Results: The mammographic findings of granulomatous lobular mastitis observed in our study group were focal or global asymmetry (52.6%), oval or round lesions with obscured margins (15.7%), irregular mass with indistinct margins (15.7%) and associated skin thickening (26.3%) with no specific pointers to differentiate from malignancy.The most common morphological abnormality on ultrasound was single or multiple collections with or without tracts (72.5%). Other morphological abnormalities were non-mass areas with tracts (25.5%), dilated ducts with debris (13.7%) and mass (3.9%). The common associated abnormalities were perilesional increased echogenicity (86.3%), increased peripheral vascularity (88.2%), intercommunicating tracts (76.5%) and axillary adenopathy (68.6%) and these ultrasound features were pointers to differentiate granulomatous mastitis from malignancy. Conclusion: Granulomatous lobular mastitis has non-specific clinical and imaging features. Imaging, especially ultrasound as in our study, is found to be indispensable in diagnosing GLM and excluding other causes such as infective mastitis and malignancy.

Granulomatous lobular mastitis is a rare inflammatory disease of the breast of unknown etiology. Most present as breast masses in women of child-bearing age. A 29-year-old female presented with a swollen, firm and tender right breast, initially misdiagnosed as mastitis. Core needle biopsy revealed findings consistent with granulomatous lobular mastitis, and cultures were all negative for an infectious etiology. She was started on steroid therapy to which she initially responded well. A few weeks later she deteriorated and was found to have multiple breast abscesses. She underwent operative drainage and cultures grew Mycobacterium fortuitum. Granulomatous lobular mastitis is a rare inflammatory disease of the breast. The definitive diagnose entails a biopsy. Other causes of chronic or granulomatous mastitis should be ruled out, including atypical or rare bacteria such as Mycobacterium fortuitum. This is the first reported case of granulomatous mastitis secondary to Mycobacterium fortuitum. With pathologic confirmation of granulomatous mastitis, an infectious etiology must be ruled out. Atypical bacteria such as Mycobacterium fortuitum may not readily grow on cultures, as with our case. Medical management is appropriate, with surgical excision reserved for refractory cases or for drainage of abscesses.

We report a case of a rare inflammatory disease, granulomatous lobular mastitis. Two weeks prior to admission the patient, a 43 year-old woman, (gravida 1, para 1) had noticed a left breast mass associated with tenderness. Palpation, gross inspection, and clinical examination, as well as the rapid growth of the mass lesion led us to believe that it was highly suspicious of malignant neoplasm. Mammography, ultrasonography, and computed tomography did not differentiate it from a malignant neoplasm. Aspiration cytology revealed an inflammatory lesion with a few clusters of epithelial cells it was diagnosed as borderline malignancy(class III) by a prudent pathologist, and thus mastectomy was performed. However, the final histologi-cal diagnosis was granulomatous lobular mastitis with no evidence of malignancy. As the clinical manifestations of granulomatous mastitis are similar to those of mammary carcinoma and, as it is an inflammatory lesion of uncertain etiology and pathogenesis, it has often been mistaken clinically for carcinoma and treated as such. Our review of the literature indicated that granulomatous mastitis most often occurs in young patients with a history of childbirth or oral contraceptive usage. Recurrence was documented in 38% of patients, and, accordingly long-term follow-up by aspiration cytology, complete resection, and adequate drug treatment with corticosteroids are recommended.

Objective To investigate the effect of the ultrasonography-guided abscess puncture aspiration or drainage combined with local application of triamcinolone acetonide in the treatment of granulomatous lobular mastitis (GLM) . Methods The clinical data of forty-six severe GLM patients from February 2015 to February 2017 were analyzed. Twenty-three patients were treated with the ultrasonography-guided abscess puncture aspiration and irrigation (control group), and the other 23 patients were treated with triamcinolone acetonide injection 40 mg from the pinpoint or a drainage tube into the abscess cavity, pressure dressing, 2 times a week after the routine abscess puncture aspiration and irrigation treatment (observation group). The recovery rate, onset time, hospitalization days and patient satisfaction were compared between two groups, and hormone related adverse reaction of observation group was observed. Results There were 17 cases with effective treatment and 1 cured case in the observation group, while 10 cases with effective treatment, no cured case and 1 case lost in control group, with statistical difference (χ2=5.15, P=0.023). Compared with the control group, the observation group had faster onset time, fewer days of hospitalization, and higher satisfaction of the patients (t=5.81, 5.80, χ2=8.09, P<0.01, <0.01, 0.004). The observation group had no obvious hormone-related adverse reactions, whereas 6 patients in the control group had side effects, which gradually disappeared after the cessation of treatment. Conclusion The ultrasonography-guided percutaneous aspiration and drainage combined with local application of triamcinolone acetonide is a choice for clinical treatment of severe GLM. Key words: Granulomatous mastitis; Carcinoma, lobular; Paracentesis; Triamcinolone acetonide

A 36-year-old Hispanic woman presented to University Hospital for further evaluation of a mass in her left breast. The mass had been present for 5 months and was painful. The past medical history was significant for human immunodeficiency virus disease, end-stage acquired immunodeficiency syndrome (CD4 count of 99 cells/mm3 and a viral load of 200,000 copies/μL), hepatitis B and C, syphilis, cytomegalovirus infection, left-sided blindness, and multiple lung nodules. There was no family history of breast cancer. Physical examination revealed a palpable 2-cm mass in her left breast. The initial workup, including mammography and a core biopsy of the mass, was performed at another hospital. The mammogram revealed a suspicious asymmetrical density at 7 o'clock. An excisional biopsy was performed at our institution and the specimen was submitted for pathologic and microbiologic evaluation.Gross examination revealed adipose tissue containing a 2.5 × 1.0 × 1.0-cm circumscribed mass that was firm and gray-tan in color. Histologic examination showed breast tissue with necrotizing granulomatous inflammation (Figure 1). The lobules contained necrotic debris and were diffusely infiltrated by epithelioid histiocytes, lymphocytes, plasma cells, occasional multinucleated giant cells, and polymorphonuclear leukocytes. Histiocytes containing multiple intracellular organisms with peripheral clearing were identified with hematoxylin-eosin stain (Figures 2 and 3). Yeast forms with narrow-based buds and nonbudding yeast forms measuring 2 to 4 μm were noted with Grocott-Gomori methenamine-silver stain (Figure 4). A similar granulomatous process was found in a biopsy of lung nodule samples. The histologic findings were confirmed with microbiologic cultures.What is your diagnosis?Histoplasma capsulatum is a thermal dimorphic fungus found primarily along the major river valleys in parts of North America. It is contracted by the inhalation of fungal spores, and infrequently causes clinical disease. Histoplasma capsulatum is an extremely rare cause of granulomatous mastitis. The organism causes a necrotizing granulomatous inflammation of the breast lobules; 2- to 4-μm yeast forms of the organism are seen within histiocytes. The definitive diagnosis is made by several mechanisms, including microscopic examination, microbiologic culture, antigen detection, and serologic tests. The main differential includes other fungal infections, Mycobacterium tuberculosis, sarcoidosis, and idiopathic granulomatous mastitis. Treatment of H capsulatum granulomatous mastitis is complete excision followed by antibiotic therapy.Granulomatous mastitis secondary to Histoplasma capsulatum is an infrequently reported entity that has been documented in women ranging from 21 to 74 years of age.1–3 Typically, the patient presents with a history of a gradually increasing unilateral breast mass. There may be overlying skin retraction and/or inflammation. There has been a report of 1 patient who also presented with axillary lymphadenopathy.2 A common mammographic finding is an asymmetrical density with a thickening of overlying skin. This dense area may be clinically and radiographically difficult to distinguish from breast cancer.1–3 The definitive diagnosis of H capsulatum is made by several mechanisms, including antigen detection in body fluids, microscopic examination of tissue and blood, isolation and characterization of the fungus in culture, and serologic tests.4The gross examination shows a firm, whitish tan, and focally necrotic mass with surrounding adipose tissue. Histologic examination reveals a necrotizing granulomatous inflammatory process involving breast lobules. The inflammatory infiltrate is composed of polymorphonuclear leukocytes, mononucleated and multinucleated epithelioid histiocytes, lymphocytes, and, occasionally, eosinophils. Histiocytes containing intracellular fungi that are morphologically consistent with H capsulatum are seen with Grocott-Gomori methenamine-silver stain, are not identified with mucicarmine staining, and occasionally demonstrate a periodic acid–Schiff reaction.2 The organism may exhibit a peripheral clearing fixation artifact on hematoxylin-eosin sections and may demonstrate narrow-based budding in the yeast form.3Histoplasma capsulatum is a thermal dimorphic fungus. It is found along the major river valleys in the temperate part of North America, and has also been reported in parts of South America, Europe, Africa, and Asia.45 Histoplasma capsulatum is contracted by the inhalation of fungal spores. In the United States, 90% to 95% of infections are asymptomatic. Clinical disease comes in 3 forms: acute pulmonary, chronic pulmonary, and disseminated. Disseminated disease, the most serious of these forms, is more likely to occur in immunocompromised individuals and those who are at the extremes of age.5 The most common sites of involvement are the spleen and liver. The adrenal gland and central nervous system are 2 of the most critical sites of presentation.46The main differential diagnosis of granulomatous mastitis secondary to H capsulatum includes other fungal infections, Mycobacterium tuberculosis, sarcoidosis, and idiopathic granulomatous mastitis. Clinical correlation as well as laboratory and radiographic studies are important in determining the correct diagnosis. Fungal organisms likely to be confused with H capsulatum in tissue sections include yeast forms of Torulopsis glabrata and Blastomycosis dermatitidis.35 Torulopsis glabrata is primarily an extracellular organism and does not exhibit a peripheral clearing fixation artifact with hematoxylin-eosin stain.3 Blastomycosis dermatitidis is a multinucleated fungal spore that demonstrates broad-based budding.5 Necrotizing granulomas are present in M tuberculosis. Acid-fast organisms are identified by Ziehl-Neelsen stain, microbiologic culture, or molecular techniques. In sarcoidosis, there are nonnecrotizing, well-circumscribed small granulomas with an associated lymphocytic infiltrate and a lack of abscess formation.7Idiopathic granulomatous mastitis has also been described as granulomatous lobular mastitis. In 1972, Kessler and Wolloch8 introduced the term granulomatous mastitis to describe nonspecific lobular granulomatous inflammation occurring in the absence of a known contributory cause. Since then, approximately 120 cases of granulomatous mastitis have been reported worldwide.9 Some proposed causes of this disease include autoimmunity, undetected organisms, oral contraception use, and a localized immune response to extravasated secretions associated with parturition and lactation.110Treatment of H capsulatum granulomatous mastitis is complete excision followed by initial treatment with amphotericin B. Continued maintenance treatment with itraconazole, fluconazole, or amphotericin B is necessary for the treatment of disseminated histoplasmosis to decrease relapse.6

Granulomatous lobular mastitis (GLM) is a rare inflammatory breast disease with unknown etiology, characterized by non-caseous granulomatous inflammation of the lobules, which infiltrate lymphocytes, neutrophils, plasma cells, monocytes, and eosinophils may accompany. GLM is often misdiagnosed as breast cancer due to the lack of specificity in clinical and imaging examinations, and therefore histopathology is the main basis for confirming the diagnosis. This review provides an overview of the pathological features of granulomatous lobular mastitis and cystic neutrophil granulomatous mastitis (CNGM, a pathologic subtype of GLM). As well as pathologic manifestations of other breast diseases that need to be differentiated from granulomatous lobular mastitis such as breast tuberculosis, lymphocytic mastopathy/diabetic mastopathy, IgG4-related sclerosing mastitis (IgG4-RSM), nodular disease, Wegener’s granulomatosis, and plasma cell mastitis. Besides, discusses GLM and CNGM, GLM and breast cancer, emphasizing that their relationship deserves further in-depth exploration. The pathogenesis of GLM has not yet been clearly articulated and needs to be further explored, pathology enables direct observation of the microscopic manifestations of the disease and contributes to further investigation of the pathogenesis.

The findings of preoperative ultrasonography in patients with granulomatous lobular mastitis treated in Xintai People′s Hospital from December 2013 to December 2016 were retrospectively analyzed. Among 15 cases of granulomatous lobular mastitis confirmed by pathology, there were 6 cases of mass type, 5 cases of tubular type and 4 cases of mixed type diagnosed by ultrasound before operation, which were consistent to pathological diagnosis in 3, 4, 3, respectively. On the ultrasound images, the blood flow signals are more rich, the tubular and mixed type have certain specificity, and color Doppler flow imaging (CDFI) usualy can make correct diagnosis. For the atypical mass lesions, the final diagnosis can be made by ultrasound-guided needle aspiration biopsy. Key words: Granulomatous mastitis; Ultrasonography

Granulomatous lobular mastitis (GLM) is an infrequent inflammatory breast disease, which can simulate malignancy on the basis of clinical and imaging features. It is typically found in parous or lactating women. The differential diagnosis of granulomatous mastitis includes infections caused by bacterial, fungal or mycobacterial agents, and autoimmune disorders like rheumatoid arthritis, sarcoidosis, giant cell vasculitis, and granulomatosis with polyangiitis. Cystic neutrophilic granulomatous mastitis (CNGM) is a sporadic sub-type of GLM that can be linked with infection with Gram-positive bacilli, specifically, Corynebacterium. It is characterised by lipogranulomas that comprise of "cystic" spaces lined by neutrophils which may contain Gram-positive rod-shaped bacteria. The majority of cases of GLM are still "idiopathic" as this pattern of inflammation still remains a mystery. We herein report three cases of CNGM and review the relevant literature. Key Words: Granulomatous mastitis, Corynebacterium, Gram-positive rods, Inflammatory breast disease, Cystic neutrophilic granulomatous mastitis.

Problem statement: Granulomatous Lobular Mastitis (GLM) or autoimmune mastitis is a rare and benign disease which, except one case reported in an old man, is usually seen during pregnancy or lactation period. This disease was described for the first time by Kessler. Approach: Our case is a 34 year-old woman who has a child with a history of using OCP that primary complaint was swelling, heat and erythema in the right breast. She was diagnosed with mastitis and treated with antibiotics for one month, later on she had experienced stiffness in the breast and a mass was also palpable. The patient was performed surgical drainage and treated with wide spectrum antibiotics being diagnosed with abscess. After one month, a solid mass was palpable so, mammography was performed and the mass was surgically resected with a suspicion of tumor. Results: The pathology report revealed granulomatous mastitis with non caseified granuloma. For Anti-TB treatment was started as medication regime and after 40 days fistula with frequent secretions appeared. Antituberculosis medications stopped and other conditions resulting in none caseified granuloma. In microscopic view granulomatous mastitis along with abscess was reported. Corticosteroids were started and the mass became smaller gradually, the fistula also closed and secretions dried out. Conclusion: Granulomatous Lobular Mastitis is a benign inflammatory breast disease. Cause of disease is still unknown, but some factors have been suggested such as local autoimmune, reaction to the delivery, previous use of contraceptives and infectious causes. The best treatment proposed is corticosteroid therapy in which the mass dwindle and the fistula is closed and secretions dried. The case is now under treatment with corticosteroids and all her symptoms have improved.

BACKGROUND: Granulomatous lobular mastitis (GLM) is an inflammatory disease of the breast, which can mimic breast cancer in clinical and radiological findings. We conducted the present study in order to determine the diagnostic and other important aspects of this disease. METHODS: In this study, we reviewed the records of 38 patients with granulomatous lobular mastitis in order to describe the clinical, imaging, laboratory, pathologic, and treatment aspects of this disease. RESULTS: All of the patients’ ages were in the range of 22-62 years (mean age: 42 years). All of them had children, history of oral contraceptive pill (OCP) usage, antibiotic therapy and mammoplasty. In physical examination, dimpling, edema, inflammation, ulcer, abscess, and firm mass were detected. Size of masses was in the range of 2 × 2 to 8 × 6 cm and their location, in most cases, was in the superior lateral quadrant or central region. In Ultrasonography, a hypoechoic fibroglandular mass and collection, and in pathologic findings, granulomatous reaction was reported. These patients were treated by antibiotics, corticosteroids, and surgery. CONCLUSIONS: GLM is a chronic inflammatory lesion of the breast which can mimic breast cancer. A history of child bearing, lactation, and OCP drug usage have suspicious roles in the formation of GLM. The most common clinical sign in these patients is a painful mass in the breast. We uncovered that clinical and radiological findings are not specific and sufficient for diagnosis of GLM. Therefore, for better diagnosis of this disease, usage of core, incisional, or excisional biopsy are recommended.

Non-puerperal mastitis (NPM) is a breast disease with poor clinical manifestations, which seriously affects women's health and quality of life. Due to the low incidence rate of the disease and the paucity of related research, there is much misdiagnosis and mis-management of periductal mastitis (PDM) and granulomatous lobular mastitis (GLM). Therefore, understanding the differences between PDM and GLM, in terms of etiology and clinical manifestations, is crucial for patient treatment and prognosis. At the same time, choosing different treatment methods may not achieve the best treatment effect, so the appropriate treatment method can often reduce the patient's pain and reduce the recurrence of the patient's disease. The PubMed database was searched for articles published from 1 January 1990 to 16 June 2022 using the following search terms: "non-puerperal mastitis", "periductal mastitis", "granulomatous lobular mastitis", "mammary duct ectasia", "idiopathic granulomatous mastitis", "plasma cell mastitis", and "identification". The key findings of the related literatures were analyzed and summarized. We systematically described the key points in the differential diagnosis, treatment, and prognosis of PDM and GLM. The use of different animal models for research and novel drugs to treat the disease were also described in this paper. The key points in the differentiation of the two diseases are clearly explained, and the respective treatment options and prognosis are summarized.

Background:Inflammatory granulomatous mastitis (IGM) is a rare benign chronic inflammatory disorder of the breast commonly seen in women of childbearing age. It is characterized pathologically by chronic granulomatous inflammation of...

Sometimes, mastitis needs to be differentiated from carcinoma because of its association with induration and with ultrasound findings (such as low-echo lesions) that resemble those in carcinoma. The aim was to define this type of mastitis and to examine 18 cases to clarify its clinicopathological features. All cases were categorized into three types: non-specific mastitis with neutrophilic infiltration (n = 7); non-specific mastitis with lymphoplasmacytic infiltration (n = 9); and granulomatous lobular mastitis (n = 2). The three types of mastitis presented similar ultrasound findings and shared certain histological features including fibrosis and diffuse or lobulocentric inflammation. Granulomatous lobular mastitis showed specific clinicopathological features including lobulocentric inflammation with giant cells, diffuse IgG4+ plasma cells, and also a high level of serum IgG4. Granulomatous lobular mastitis could be categorized into IgG4-related and non-IgG4-related granulomatous lobular mastitis. IgG4 immunohistochemistry serum IgG4 might be useful for diagnosis of IgG4-related granulomatous lobular mastitis and could help to avoid overtreatment such as wide excision.

Objective: Granulomatous lobular mastitis (GLM) is a rare and benign disorder of the breast, of unknown etiology. Differential diagnosis by radiological and clinical evaluation remains uncertain. There is no optimal treatment for this disorder. In this study, we aimed to analyze 17 cases with GLM retrospectively with the help of clinical and radiologic studies and to give detailed information about outcomes. Materials and Methods: A retrospective chart review of 17 consecutive patients with granulomatous lobular mastitis (GLM), who were treated in Kartal Education and Research Hospital between March, 2004 and January, 2011,was carried out in our study. Results: All the cases were women of childbearing age, who had given birth and breastfed at least once. The most common causes for admission were; breast mass in 12 patients (70.6%) and pain in 12 (70.6%) cases. Five (29.4%) cases developed a fistula and four (23.5%) had abscess requiring drainage. Mammography was used for 10 (58.8%) cases, 12 (70.6%) were examined by MRI and all the patients were evaluated with ultrasound. Five (29.4%) cases were suspicious for malignancy prior to biopsies. Diagnoses of sixteen (94.1%) cases were established with tru-cut biopsy. Fourteen (82.3%) cases underwent wide local excision (WLE) following antibiotic therapy and/or drainage and 3 (17.6%) cases with diffuse disease also underwent wide local excision following therapy with antibiotics and/or drainage and steroids (prednisolone 32 mg bid). Complete remission was observed in one patient with diffuse disease who was referred to our clinic with excisional biopsy after steroid therapy (prednisolone 32 mg bid). Relapse developed in two (11.7%) cases in the end of thirty-six months of median follow-up. Both patients were treated with steroids (prednisolone 32 mg bid). Conclusion: GLM is a benign disorder and has no widely accepted treatment. Wide local excision may be performed successfully in the management of GLM alone or following a steroid therapy in those patients with diffuse involvement.