1 / 42

MANAGEMENT OF IDIOPATHIC GRANULOMAT OUS MASTITIS

MANAGEMENT OF IDIOPATHIC GRANULOMAT OUS MASTITIS. Canon CHAN Department of Surgery, North District Hos pital. Hong Kong SAR. Idiopathic Granulomatous Mastitis (IGM). Kessler and Wolloch 1972 Cohen 1977 Chronic granulomatous lobulitis Absence of an obvious etiology.

axl
Download Presentation

MANAGEMENT OF IDIOPATHIC GRANULOMAT OUS MASTITIS

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. MANAGEMENT OF IDIOPATHIC GRANULOMATOUS MASTITIS Canon CHAN Department of Surgery, North District Hospital. Hong Kong SAR

  2. Idiopathic Granulomatous Mastitis (IGM) • Kessler and Wolloch 1972 • Cohen 1977 • Chronic granulomatous lobulitis • Absence of an obvious etiology Kessler E, Wolloch Y. Am J Clin Pathol, 1972 Cohen C. S Afr Med J 1977

  3. Introduction • Rare inflammatory breast disease • Unknown etiology • Women of childbearing age • Simulate breast cancer • Breast mass • Nipple retraction Sakurai et al. Breast Cancer 2002 Cakir et al. Breast J 2002

  4. Introduction • Diagnosis is one of exclusion • Infectious and noninfectious causes • Carcinoma/ carcinomatous mastitis • Wegener granuloma • Sarcoidosis • Tuberculosis • Histoplasmosis Erhan et al. Breast 2000

  5. Topic of interest • The pathogenesis is not clear • Etiology unknown • Treatment strategy controversial

  6. Current arguments • An etiology for an idiopathic disease? • Oral contraceptive pills • Pregnancy and lactation • Infective • Autoimmune process • Immune response to extravasated secretions from lobules Kessler et al. Am J Clin Pathol. 1972 Cohen et al. S Afr Med J. 1977 Brown et al. Am J Surg. 1979 Imoto et al. Jpn J clin Oncol. 1997 Cserni et al. Breast J. 1999

  7. IGM - Presentation • Pain • Swelling/ mass • Discharge/ galactorrhoea • Nipple retraction • Skin ulcers

  8. IGM – Physical examination • Skin ulceration • Mass • Induration • Abscess • Fistula • Enlarged lymph node • Up to 15% of cases Asoglu et. al The Breast Journal. 2005

  9. IGM - Investigations

  10. IGM - investigations • Manage as a breast mass • Mammography (MMG)/ Ultrasound (USG)/ Magnetic Resonance Imaging (MRI) • Fine needle aspiration cytology (FNAC) • Core biopsy

  11. Mammography in IGM • Oblique view demonstrates a diffusely increase asymmetric density and enlarged axillary lymph nodes Asoglu et. al The Breast Journal. 2005

  12. Mammography and IGM • Small, multiple, ill-defined masses without microcalcification • Most commonly reported finding of IGM is an asymmetrically increased density without a distinct margin or mass effect, though this is not specific • Low sensitivity caused by dense breast tissue limits the value of MMG in this age group • In patients having dense breast parenchyma, MMG may be negative Memis A et al. Clin Radiol. 2002 Han BK et al. AJR Am J Roentgenol. 1999

  13. Ultrasound and IGM • Hypoechoic indistinctly bordered heterogeneous masses • May be connected by a few tubular hypoechoic structures Kocaoglu et al. J Comput Assist Tomogr.2004

  14. MRI and IGM • Segmental heterogeneity • Hypointense on precontrast T1-weighted images and hyperintense on T2-weighted sequences • Postcontrast dynamic T1-weighted scans showed heterogeneously enhancing ring-like abscesses • Abscess walls reveal a benign type time-signal intensity curve (gradual and progressive enhancement without washout) Kocaoglu et al. J Comput Assist Tomogr.2004

  15. Imaging and IGM • Idiopathic granulomatous mastitis is rare; hence, the number of patients in these studies can not make generalizations • Biopsy still remains the golden method of definite diagnosis

  16. IGM - FNAC • The cytological diagnosis is difficult and often does not deliver any diagnostic information • ~30% can be diagnosed by FNAC only • The absence of necrosis and a predominantly neutrophil infiltrate in the background favor the diagnosis • these signs overlap with other etiologies: Tuberculosis Azlina AF et al. World J Surg 2003 Sakurai T et al. Breast Cancer. 2002 Kumarasinghe MP Acta Cytol. 1997 Imoto S et al. Jpn J Clin Oncol. 1997

  17. IGM - Biopsy • Gold standard in diagnosis of IGM • Histological features • Granulomas (100%) • Background of inflammatory infiltrate (88%) • Foamy macrophages and multinucleated giant cells (65%) • Microabscesses • The ducts appear normal without evidence of malignancy or caseation • Stains for fungi and acid-fast bacilli are negative Ramachandram K et al. Pathology. 2004

  18. Histological review High power view Low power view Multinulceate Giant cells and lymphocyts set in an area of stellate fibrosis Epithelioid histiocyts and neutrophilic leukocytes Courtesy of Dr. TY Yau Department of Pathology, QEH HKSAR

  19. IGM - Treatment

  20. Current Arguments • Management options • Surgical excision • Wide local excision +/- reconstruction • Invasive procedure for a benign disease entity • Systemic steroid/ immunosuppressant • Immune suppression • Underlying infective cause renders its use a concern

  21. Surgical excision • Asoglu et al. The Breast J. 2005. • 18 patients with IGM • All underwent surgical excision with negative margins • Mean follow up 18 months • Recurrence rate 6%

  22. Prednisolone management • DeHertogh et al. N. Eng. J. Med. 1980. • Short course high dose prednisolone • Single patient case report • Short follow up period • Recurrence was not reported • Azlina et al. World J Surg. 2003. • 25 patients with mean follow up of 6.5 months • Recurrence up to 50% for steroid treatment • Short follow up period

  23. Conservative Management • Lai et al. Breast Journal. 2005. • 9 women with mean followed up of 18.7 months • 50% spontaneous complete resolution after 14.5 months • Small size review

  24. Conservative vs Surgery • Al-Khaffaf et al. J Am Coll Surg.2008 • 18 patients wth IGM • 25 years retrospective review • FU period not mentioned • Steriod use/ antiobiotic/ surgical procedures compared • Overall outcomes were not related to any combination of treatment options • All patients spontaneously resolved regardless of treatment used, it may be best to let this condition “burn out.”

  25. MANAGEMENT OF IDIOPATHIC GRANULOMATOUS MASTITISEXPERIENCE FROM A REGIONAL HOSPITAL CANON CHAN, N. S. C HO, M. POON, M. T. CHEUNG Department of Surgery, Queen Elizabeth Hospital. Hong Kong SAR

  26. Objective This study is aimed to determine the best treatment modality for IGM

  27. Queen Elizabeth Hospital

  28. Methods • A retrospective review • Twenty three women with histopathologic diagnosis of IGM between 1997 and 2006 was performed • The difference in presentation, recurrence and outcome between those treated by surgical intervention and those managed conservatively were assessed

  29. Results • The women had a mean follow-up of 22.7 months and a mean age of 40 years (range 22-55 years) • Clinically and radiologically, 13% of the women were suspected to have malignancy • All patients had unilateral involvements • None of the patient were pregnant or lactating • None of the patient were given systemic steroid therapy

  30. Results • Presentation

  31. Risk Factors

  32. Drug

  33. Results • Treatment

  34. Results – Expectant management • 91% of the patients had spontaneous complete resolution of disease without recurrence • Mean interval of 12 months. • Remaining patients had either recurrence (4.5%) or static disease (4.5%)

  35. Results – Surgical treatment • 85% of patients had resolution of disease after either lumpectomy or surgical drainage of abscess • Two patients (15%) had disease recurred and one of them (7.5%) eventually became static after followed up for 24 months

  36. Patient Characteristics

  37. Recurrent/ static cases

  38. Conclusions • It is important to exclude malignancy by histopathology in IGM • The presence of a breast mass in a woman with history of hormonal therapy or antipsychotic drug use should alert the differential diagnosis of IGM • Our results suggest expectant management with close regular surveillance has an acceptable recurrence rate of 4.5% and it is the treatment of choice for patients with IGM

  39. Hyperprolactinaemia and IGM? • Antipsychotics block D2 receptors on lactotroph cells and remove inhibitory influence on prolactin secretion • Seen in 40-60% of antipsychotic users • Causes breast enlargement and galactorrhoea • Baseline levels take up to 3 weeks to return to normal • No study has yet looked into the association between antipsychotic usage and IGM Wieck, A.et al. British Journal of Psychiatry. 2003.

  40. Future study • Randomized controlled trial • Difficulty lies in the rarity of this disease entity • Relationship between antipsychotics and IGM • Elevated serum prolactin level? Cserni G, Szajki K. Breast J., 1999 Rowe PM. Br. J. Clin. Pract. 1984

  41. Thank you

  42. IGM in the male breast Reddy et al. The Breast Journal. 2005

More Related