Cytomorphological Spectrum of Granulomatous Mastitis: A Study of 33 Cases.

Since idiopathic granulomatous lobular mastitis, also known as idiopathic granulomatous mastitis or granulomatous lobulitis, was first described by Kessler and Wolloch in 1972, no consensus on the ideal and definitive treatment for this phenomenon has been reached thus far. Idiopathic granulomatous lobular mastitis mostly frequently observed in women of childbearing age within a few years of pregnancy with a higher incidence in patients of Hispanic, Native American, Middle Eastern, and African descent. This entity, per se, is a rare, benign, chronic inflammatory breast condition of unknown aetiology mimicking two common breast disorders. The first is breast inflammations or infection, such as cystic neutrophilic granulomatous mastitis; granulomatous mastitis due to Corynebacterium;other infections with granulomas, mycobacteria, fungi, cat scratch disease, and Brucella; granulomatosis with polyangiitis (Wegener's granulomatosis); sarcoidosis; and squamous metaplasia of lactiferous ducts. The second is breast carcinoma in some challenging cases. Of note, no consensus, per se, has been declared on its therapeutic management. The following vignette case described in this report involves idiopathic granulomatous lobular mastitis imitating breast carcinoma. It is important to note that, the aetiology of idiopathic granulomatous lobular mastitis is unknown, its diagnosis is difficult, and physicians should be vigilant and aware of this condition in order of abstaining from an overtreatment for malignancy or overlooking a true malignancy.

Idiopathic granulomatous lobular mastitis (IGLM) is an uncommon and rare chronic inflammatory breast disease. The exact etiology is not known. Although various etiologies have been implicated, autoimmunity is favored and widely accepted. In countries with a high prevalence of tuberculosis, the diagnosis of IGLM is often challenging. Clinical presentation is quite variable. Ultrasonography and mammography findings lack specificity. Fine-needle aspiration (FNA) cytology features of idiopathic granulomatous mastitis (IGM) have been described in few reports, but they are still debatable. We report the case of a 36-year-old female with a hard lump in the left breast. Aspiration cytology smears showed many well-formed epithelioid granulomas and few scattered epithelioid cells. The background showed numerous polymorphonuclear leukocytes with few reactive lymphoid cells and foreign-body giant cells. There was no necrosis. Acid-fast bacilli (AFB) and fungal stains did not show AFB and fungal hyphae. A diagnosis of IGM was suspected on aspiration cytology. Histopathology examination confirmed the diagnosis. To conclude, though tuberculosis is highly prevalent in India, if breast FNA smears show epithelioid granulomas with numerous polymorphonuclear leukocytes with no necrosis or AFB, IGLM must be suspected.

In this study we aimed to define clinical, radiologic and pathological specialties of patients who applied to General Surgery Department of Atatürk University Medical Faculty with granulomatous mastitis and show medical and surgical treatment results. With the help of this study we will be able to make our own clinical algorithm for diagnosis and treatment. We searched retrospectively addresses, phone numbers and clinical files of 93 patients whom diagnosed granulomatous mastitis between a decade of January 2001 - December 2010. We noted demographic specialties, ages, gender, medical family history, main complaints, physical findings, radiological and laboratory findings, medical treatments, postoperative complications and surgical procedures if they were operated; morbidity, recurrence and success ratios, complications after treatment for patients discussed above. In this study we evaluated 93 patients, 91 females and 2 males, with granulomatous mastitis retrospectively who applied to General Surgery Department of Atatürk University Medical Faculty between January 2001 and December 2010. Mean age was 34.4 years. The diagnosis was confirmed by histopathologic examination of the lesions. Seventy three patients had idiopathic granulomatous lobular mastitis and 20 patients had specific granulomatous mastitis IGM (18 tuberculosis mastitis, 1 alveolar echinococcosis and 1 silk reaction). All the patients had surgical debridement or antibiotic, and anti-inflammatory treatment with results bad clinical response before applied our clinic. Empiric antibiotic therapy and drainage of the breast lesions are not enough for complete remission of idiopathic granulomatous mastitis. The lesion must be excised completely. In selected patients, corticosteroid therapy can be useful. In the patients with tuberculous mastitis, abscess drainage and antituberculous therapy can be useful, but wide excision must be chosen for the patients with recurrent disease.

Granulomatous mastitis (GLM) is a rare and complex chronic inflammatory disease of the breast with an unknown cause and a tendency to recur. As medical science advances, the cause, treatment strategies, and comprehensive management of GLM have increasingly attracted widespread attention. The aim of this study is to assess the development trends and research focal points in the GLM field over the past 24 years using bibliometric analysis. Using GLM, Granulomatous mastitis (GM), Idiopathic granulomatous lobular mastitis (IGLM), and Idiopathic granulomatous mastitis (IGM) as keywords, we retrieved publications related to GLM from 2000 to 2023 from the Web of Science, excluding articles irrelevant to this study. Citespace and VOSviewer were employed for data analysis and visualization. A total of 347 publications were included in this analysis. Over the past 24 years, the number of publications has steadily increased, with Turkey being the leading contributor in terms of publications and citations. The University of Health Sciences, Istanbul University, and Istanbul University Cerrahpasa were the most influential institutions. The Breast Journal, Breast Care, and Journal of Investigative Surgery were the journals that published the most on this topic. The research primarily focused on the cause, differential diagnosis, treatment, and comprehensive management of GLM. Issues related to recurrence, hyperprolactinemia, and Corynebacterium emerged as current research hotspots. Our bibliometric study outlines the historical development of the GLM field and identifies recent research focuses and trends, which may aid researchers in identifying research hotspots and directions, thereby advancing the study of GLM.

BackgroundIdiopathic granulomatous lobular mastitis is a rare chronic inflammatory disease of the breast. Idiopathic granulomatous lobular mastitis is a benign entity of unknown etiology occurring mainly in women of reproductive age that can clinically and radiologically mimic breast carcinoma, making diagnosis both challenging and delayed.Case presentationA 38-year-old otherwise healthy Indonesian female patient presented with a painful and enlarging mass of the left breast with overlying erythema that was unresponsive to antibiotic therapy. Regional lymphadenopathy and mammography findings were concerning for inflammatory cancer of the breast. The patient eventually developed erythema nodosum and polyarthralgia, coupled with histopathology confirmation, leading to a diagnosis of idiopathic granulomatous lobular mastitis. Complete symptom resolution was achieved using immunosuppressive treatment with systemic steroids and localized intralesional steroids. The patient remained asymptomatic with no disease relapse at 3-year follow-up using a conservative approach to treating idiopathic granulomatous lobular mastitis, with high patient satisfaction.ConclusionIdiopathic granulomatous lobular mastitis is a rare and diagnostically challenging condition that clinically and radiologically mimics breast carcinoma. A high index of clinical suspicion is required for diagnosis. Histopathology is recommended over clinical imaging studies if idiopathic granulomatous lobular mastitis or breast cancer are suspected. Due to the rarity of this condition, this case report provides valuable insight into the diagnostic approach, differential diagnosis, associated radiological and histopathological findings, and treatment options, and also serves as a reference for successful treatment of idiopathic granulomatous lobular mastitis using conservative local and systemic immunosuppressive therapies with no clinical relapse for 3 years. Multidisciplinary approach is needed to prevent diagnostic delay and provide optimal therapeutic management and outcome.

Idiopathic granulomatous mastitis (IGM) is an uncommon chronic inflammatory lesion of the breast with an uncertain optimal treatment regimen, the physical examination, and radiologic features of which may be confused with breast carcinoma. In this study, we aimed to describe the clinicopathologic characteristics of 33 patients who admitted to our breast policlinic and took the diagnosis of granulomatous (idiopathic and non-idiopathic) mastitis, and report the place of corticosteroids and the timing of surgery in the treatment of patients with IGM. The clinical features of 33 patients who presented to our breast policlinic with the complaint of breast mass and reached the final diagnosis of GM between March 2005 and October 2009 were reported. The most common symptoms were mass (n: 27) and pain (n: 11). Ultrasonography (USG) and biopsy were performed in all of the patients. Mammography (MMG) was performed in 9, and magnetic resonance imaging (MRI) in 10 patients. The diagnosis of idiopathic lobular granulomatous mastitis (ILGM) was made in 25 patients and tuberculous mastitis (non-idiopathic GM) in the remaining 8 patients. Twenty-four patients received steroid treatment except one who was pregnant. After giving birth, she also received steroids. One of the patients who developed recurrence after 11 months repeated the steroid therapy. Eight patients with tuberculous mastitis were placed on a regimen of antituberculosis therapy for 6 months. In the diagnosis of IGM, physical examination, USG, MMG, and even MRI alone may sometimes not be enough. They should be discussed altogether and the treatment should begin after definitive histopathologic result. Fine needle aspiration biopsy for cytology will result in a high level of diagnostic accuracy, however, core biopsy will reinforce the exact result. Corticosteroid therapy has been shown to be efficacious for IGM, but in the existence of complications such as abscess formation, fistulae, and persistent wound infection, surgical treatment has been the first method of choice.

A 36-Year-Old Woman With a Unilateral Breast Mass

Idiopathic granulomatous mastitis, also known as idiopathic granulomatous lobular mastitis, is a benign breast lesion that represents both a diagnostic and therapeutic dilemma. We report two cases of granulomatous mastitis recently evaluated and managed at our institution. To better understand this rare disease, we analyzed treatment outcomes in reported cases of granulomatous mastitis. One hundred sixteen cases were subsequently analyzed. Primary management strategies included observation (n = 9), steroids (n = 29), partial mastectomy (n = 75), and mastectomy (n = 3). Success rates with each treatment were observation, 56 per cent; steroids, 42 per cent; partial mastectomy, 79 per cent; and mastectomy, 100 per cent. Based on this analysis, we propose a clinically useful algorithm for both workup and management of these challenging cases.

Idiopathic granulomatous lobular mastitis (IGLM), also known as idiopathic granulomatous mastitis, is a rare chronic inflammatory lesion of the breast that can clinically and radiographically mimic breast carcinoma. The aim of this study was to describe the radiological imaging and clinical features of IGLM in order to better differentiate this disorder from breast cancer. We performed a retrospective analysis of the clinical and radiographic features of 11 women with a total of 12 IGLM lesions. The ages of these women ranged between 29 and 42 years, with a mean age of 34.8 years. Ten patients were examined by both mammography and sonography and one by sonography alone. The sites that were the most frequently involved were the peripheral (6/12), diffuse, (3/12), and subareolar (3/12) regions of the breast. The patient mammograms showed irregular ill-defined masses (7/11), diffuse increased densities (3/11), and one oval obscured mass. In addition, patient sonograms showed irregular tubular lesions (7/12) or lobulated masses with minimal parenchymal distortion (2/12), parenchymal distortion without definite mass lesions (2/12), and one oval mass. Subcutaneous fat obliteration (12/12) and skin thickening (11/12) were also observed in these patients. Contrary to previous reports, skin changes and subareolar involvement were not rare occurrences in IGLM. In conclusion, the sonographic features of IGLM show irregular or tubular hypoechoic masses with minimal parenchymal distortion. Both clinical information and the description of radiographic features of IGLM may aid in the differentiation between IGLM and breast cancer, however histological confirmation is still required for the proper diagnosis and treatment of the disorder.

Granulomatous mastitis is a rare, uncommon chronic inflammatory condition of the breast. The condition is a well-known mimicker of malignancy, both clinically and radiographically. Diagnostic dilemmas arise frequently in such cases, which delay the treatment. In the present study, we studied the cytomorphological features in cases of granulomatous mastitis diagnosed by fine needle aspiration cytology (FNAC) to attribute the clinical and radiological findings to each case. A total of 13 cases with cytological diagnoses of granulomatous mastitis were reviewed and studied. Fine needle aspiration was performed on these patients, and smears were examined. In this study, the cytomorphological features were studied in depth and correlated with clinical and radiological findings. Ziehl-Neelsen stain and/or Truenat were performed in all 13 cases. Clinical examination revealed a lump in the breast in all the patients and a lump with pus discharge in two patients. Ultrasonographic examination suggested an inflammatory pathology in most of the cases. The smear examination showed diverse cytomorphological features, ranging from epithelioid cell granuloma to a vague collection of histiocytes, multinucleated giant cells, neutrophils, plasma cells, and a few lymphocytes. In four cases, there was prominent emperipolesis of neutrophils. Additionally, granulomatous mastitis was diagnosed in accessory axillary breasts in one of the cases. Based on cytomorphological features and after excluding commonly encountered granulomatous infective pathology, a diagnosis of granulomatous mastitis was made. In addition, the cytological diagnosis rests on finding histiocytes with neutrophils, giant cells, and epithelioid cell granulomas with or without necrosis and excluding other common differential diagnoses like tuberculosis, fungal infection, and Rosai-Dorfman disease. It is important to keep a possibility of granulomatous mastitis in women presenting with painful nodular breast lumps. Aggressive management of other specific etiological causes of granulomatous mastitis can be avoided with an accurate cytological diagnosis of idiopathic granulomatous mastitis.

Idiopathic granulomatous lobular mastitis (IGLM) is a rare, chronic inflammatory breast disease without a known etiology. Even though the current literature proposes several treatment strategies, there is no universal consensus for long-term management. A 43-year-old White woman (gravida 5, para 4) presented with a 2-week history of right lower outer quadrant breast tenderness, heaviness, warmth, and redness. Mammography and ultrasound were concerning for inflammatory breast cancer. Biopsies returned as granulomatous mastitis without malignancy. After 8 months of unsuccessful therapy with prednisone and methotrexate, surgeons excised the breast tissue. Cultures and special stains were negative for other organisms. At the 7-month follow-up, no evidence of recurrence was seen. As there remains no consensus behind the etiology or management of IGLM, our case demonstrates a reasonable and successful stepwise treatment beginning with medical therapy before proceeding to surgical cure. Because of possible malignancy risk with chronic IGLM, patients should not delay surgical excision if their condition remains refractory to medical therapy alone.

Idiopathic granulomatous mastitis (IGM) is a rare benign inflammatory disease of the breast of unknown etiology. The typical clinical presentation is a unilateral palpable breast mass with pain and overlying skin erythema. IGM remains a diagnosis of exclusion, and it is necessary to exclude all infectious and noninfectious causes of granulomatous disease. Definitive diagnosis of IGM relies on histological examination, demonstrating granulomatous inflammation without caseous necrosis. Common medical treatment entails the use of corticosteroids and other immunosuppressive agents in patients with IGM. We present a rare case of bilateral IGM in a patient found to have latent tuberculosis (TB), and we discuss the challenges of treating IGM in a tuberculin skin test positive patient. The patient is a 44-year-old female veteran with a history of a positive tuberculin skin test who initially presented with a unilateral painful breast mass. She continued to present with recurrent painful breast masses that progressed to bilateral disease. Mammography and breast MRI were suspicious for malignancy and required biopsy. Histopathology revealed noncaseating granulomas. All stains and cultures were negative for mycobacterium. After 3 years, the disease subsided and she did not present with any further recurrences. She was subsequently treated with isoniazid to reduce the risk of TB reactivation. The diagnosis of IGM is challenging and should be considered in the differential diagnosis of persistent or recurrent breast masses. Patients with IGM found to have latent TB are of particular concern, and tuberculous mastitis must be carefully excluded. IGM is generally a self-limiting disease, and treatment options include observation, symptomatic palliation, steroids, and in complicated recurrent cases or cases involving an abscess, surgery may be considered as a last resort. Treatment of IGM in patients with latent TB should be primarily symptomatic, and steroids should not be used. J Med Cases. 2014;5(8):430-434 doi: http://dx.doi.org/10.14740/jmc1835w

INTRODUCTION AND OBJECTIVES:
 Granulomatous mastitis is rare chronic inflammatory benign breast lesion, which clinically and radiologically resembles carcinoma breast thus creating a diagnostic dilemma. The term granulomatous mastitis includes two broad categories namely specific granulomatous mastitis for which aetiological factors can be defined such as infectious causes like Mycobacterium tuberculosis, blastomycosis, cryptococcosis, histoplasmosis, actinomycosis and filarial infection. Other factors include association with autoimmunue diseases such as Wegner’s granulomatosis and giant cell arteritis and there are other rare causes such as include duct ectasia, foreign body reaction and fat necrosis which also leads to granulomatous lesions of breast.
 Cytological features of granulomatous mastitis(GM) have not been widely discussed and described in literature, so through this study we have made an attempt to thoroughly discuss cytological spectrum of granulomatous mastitis.
 MATERIALS AND METHODS:
 A retrospective study was performed over a period of four years from 2016 to 2019. A total of 465 cases of breast lump reported to cytopathology section out of which 24 cases of GM diagnosed on FNAC were included in our study. Results of Erythrocyte sedimentation rate (ESR) and Mantoux test along with TB-PCR were recorded. FNAC slides were retrieved pertaining to study period.
 Granulomatous lesions of breast were further categorized broadly into IGM/ NGM, granulomatous mastitis without caseous necrosis and tubercular mastitis where diagnosis were made definite on basis of demonstration of AFB or positive TB-PCR .
 RESULTS:
 Patient age ranged from 23 years to 55 years with the mean age of 36.6 years with maximum of patients falling in second decade followed by third decade. Granulomatous lesions were broadly categorized into Idiopathic/ Non specific granulomatous mastitis(11 cases,45.8%), GM with caseous necrosis(8 cases, 33.3%) and tubercular mastitis(5 cases, 20.9%). Histopathology was available in 7 cases(29.2%). TB-PCR was sent in all cases of granulomatous mastitis diagnosed on cytology and was positive in 10 cases(41.7%).
 CONCLUSION:
 Idiopathic granulomatous mastitis and tubercular mastitis are rare inflammatory diseases of breast which mimic malignancy clinically and radiologically. FNAC plays important role in diagnosis of granulomatous diseases of breast and also their differentiation from malignant tumors. Tubercular mastitis needs to be differentiated from IGM since treatment options are different in both the cases. Cytopathology plays an important role in differentiationg both the diseases supplemented by radiological and microbiological investigations.
 The present study thus highlights the importance of FNAC as an infalliable tool in diagnosis of granulomatous mastitis and its differentiation from neoplastic lesions of breast thus avoiding time consuming histopathological work up of cases.

Granulomatous mastitis (GM) is often clinico-radiologically misdiagnosed as breast malignancy. Tuberculosis, foreign body reactions, fungal and parastic infections, and autoimmune diseases can cause GM. The present study aimed to assess the spectrum of GM on fine-needle aspiration biopsy (FNAB) smears along with its histopathological and clinico-radiological findings. It was a retrospective study which included all cases of GM diagnosed onFNABover a period of 3 years. The histopathological diagnosis was retrieved, wherever possible. All the FNA smears and histopathological sections were reviewed for the presence of epithelioid granulomas, necrosis, epithelioid histiocytes, inflammatory cells including plasma cells, neutrophils, eosinophils, multinucleated giant cells, and epithelial component and associated atypia, if any. The inflammatory cells and multinucleated giant cells were graded on a scale of 0 to 3+ in every case. Among the 22 cases evaluated, the most common inflammatory infiltrate was lymphocyte followed by neutrophils and eosinophils. Caseous necrosis was appreciated in 7 (31.8%) cases, out of which 5 (22.7%) were diagnosed as tubercular mastitis on FNA smears. Ziehl Neelson stain was done in all FNAB smears and AFB was positive in 7 (31.8%) cases. Histopathological correlation was available for 14 cases (63.6%). The most common diagnosis on histopathology was idiopathic GM having lobulo-centric granulomatous inflammation, epithelioid histiocytes, neutrophils, and lymphocytes. FNAB is a reliable and minimally invasive tool to diagnose tubercular mastitis, idiopathic GM and also ruling out clinicoradiological suspicion of malignancy. Careful examination of cytological smears can prevent an unnecessary biopsy in granulomatous lesions of breast.

Background: Granulomatous mastitis can be divided into idiopathic granulomatous mastitis and granulomatous mastitis occurring as a rare secondary complication of a great variety of other conditions such as tuberculosis and other infections, sarcoidosis and granulomatosis with polyangitis. Idiopathic granulomatous mastitis (IGM) is an uncommon benign chronic inflammatory disease which can clinically and radiographically mimic abscess or breast cancer. Definitive diagnosis was made by histopathology and exclusion of an identifying etiology. Optimal treatment has not been yet established. Objectives: The aim of this study was to report and describe the clinical signs, radiological findings, managements, clinical course, and clinical outcomes after treatment of IGM. Materials and Methods: We conducted a descriptive cross-sectional study on 28 patients with chronic GM in Enam Medical College & Hospital collected in 1 year. The patient characteristics, clinical presentations, radiological findings, microbiological workups, tissue pathology, treatment modalities, outcomes were analyzed. We evaluated only the response of wide local excision and assess the recurrence up to 2 years after surgery on the treatment modalities to find out the proper treatments for chronic GM patient. Results: Twenty eight patients were diagnosed as chronic granulomatous mastitis. FNAC was conducted before excision. Twenty seven patients had chronic granulomatous mastitis and one patient had tuberculosis on histopathology. In the first setting, 28 patients were treated by surgery. Thirteen patients out of 28 had open wound after performing an excision in which healing by secondary intention was done. Ten patients had undergone primary closure and no complications. Conclusion: Chronic GM is an uncommon benign disease which is hardly distinguished from malignancy. There is not a significant difference among treatment modalities in term of time-to-healing and recurrence of disease. The result shows that surgery is outperformed by the shortest healing time. However, the surgical treatment must be chosen with careful due to high rate of wound complications. Multimodality treatment is recommended as the proper treatments for chronic GM patient. J Enam Med Col 2020; 10(3): 174-178