SEMIOLOGY AND DIFFERENT CAUSES OF GRANULOMATOUS MASTITIS

1. SEMIOLOGY AND DIFFERENT CAUSES OF GRANULOMATOUS MASTITIS A. SAIDANE, N. DALI, I. MARZOUK, A. FENNIRA, A. MANAMANI, L. BEN FARHAT, L. HENDAOUI Radiologydepartment, MongiSlimHospital of Marsa, Tunis

2. Granulomatousmastitisis a rare begninimflammatorybreastdiseasethatmostlyoccurs in women of childbearingage. • The main diagnosisdifficultyisthatitcanclinically and radiologicallymimic an inflammatorybreastcarcinoma. • Idiopathicform has to bedistingueshedfromthosesecondary to infections and other causes INTRODUCTION

3. We report the cases of 3 patients whoseage ranges between 45 and 59 years. • Theywere all explored by mammography, ultrasonography and percutanousbiopsy. • The histologicalexaminationconfirmed the diagnosis MATERIALS & METHODS

4. A 53 yearsoldwomen. • No medicalhistory. • Progressivelyworseninginflammatory lump of the leftbreastwith skin ulceration and induration. RESULTS: CASE 1

5. MAMMOGRAPHY: • ill-definedopacity of the upperouter quadrant • nippleretraction • skin thickening • round macrocalcification RESULTS: CASE 1

6. hypoechoicspiculatedtissularlesionwithposteriorshadowingassociated to linearhypoechoic band joining the skin (arrow)

7. HISTOLOGY: polymorphous inflammatory infiltrate  made of lymphocytes, plasmocytes  ​​and neutrophils mixed with Langhans giant cells and epithelioid cells and no caseous necrosis but an immunohistochimic study confirm the diagnosis of tuberculosis. SECONDARY GRANULOMATOUS MASTITIS RESULTS: CASE 1

8. A 45 yearsoldwomenwithno medical history. • Adressed for an inflammatory induration of the leftbreast • The physicalexaminationrevealed an entirehyperemic, edematous, firm and painfulleftbreastwith multiple fistulous orifices on the skin letting out a purulent discharge RESULTS: CASE 2

9. Diffuse densityincrease RESULTS: CASE 2 • Skin thickening • No architectural distorsion • Raound calcifications

10. Hypoechoicheterogenous and ill-defined mass Hypoechoic linear band indicating a fistulous path Posteriorshadowing RESULTS: CASE 2 Intramammarylymphnode

11. HISTOLOGY: • Manyinflammatorygranulomatousfociincluding the lobules and made of lymphocytes, plasmocytes, histiocytes and epithelialcells.  • There werealso micro-abscesses IDIOPATHIC GRANULOMATOUS MASTITIS RESULTS: CASE 2

12. A 59 yearsoldwomen. • Fibroadenoma of the leftbreast, operated 5 yearsago.  • Iterativemammographic and ultrasonographiccontrols RESULTS: CASE 3

13. intra mammary lymph nodes ( ) Densityincrease in the upperouter quadrant ( ) Axillarylymphnode ( ) RESULTS: CASE 3 Skin thickening ( )

14. Hypoechoic mass withirregularborders RESULTS: CASE 3 Intra mammarylymphnode

15. HISTOLOGY: Granulomatousreaction made of giant and epithelioidcellssurrouding a foreign body (suture thread) SECONDARY GRANULOMATOUS MASTITIS RESULTS: CASE 3

16. The granulomatousmastitis has to bedifferenciated in twoforms: • the idiopathicformisnamedIdiopathicGranulomatousLobularMastitis (IGLM) • the secondaryforms are caused by other • etiologies of chronic inflammatory breast diseases, • such as plasma cell mastitis, Wegener’s • granulomatosis, rupturedcyst, sarcoidosis, • fat necrosis, tuberculosis, carcinoma, • duct ectasia, and fungal infection [1] DISCUSSION

17. The IGLM was first described in 1972 by Kessler and Wolloch [1,3]. • It occursmainly in women of childbearingage, especiallyat the thirddecade and it’sfrequently • associated with recent childbirth (ranging from 2 • months to 15 years since the last delivery) [1, 2, 5]. • However, the age of our 2 IGLM patients do not match these datas. DISCUSSION: IGLM

18. Its cause is unclear. Nevertheless, an autoimmune origin, possibly against protein secretions in the ducts, is favored [1]. • The positive response of IGLM to steroids strenghtens that hypothesis. • Conflicting data exists regarding the role of oral • contraceptive use. However, no true associations with • pregnancy, breast-feeding, prolactin levels, or oral contraceptive use have been established to date [5] • The mammographic findings are not specific. DISCUSSION:IGLM

19. Han et al. [7] described multiple small masses or a large focal asymmetric density but no changes involving the skin or the nipple. • Lee et al. [2] showed an irregularill-defined • mass to be the most common finding, skin thickening was observed in more than 60% of the cases and benign-lookingaxillarylymphnode in nearly 55%, whichisconfirmed by our 2 cases. • The lesions are usuallyunilateral and can affect any quadrant except the subareolarregionwhichis an exceptionnal location[2] DISCUSSION:IGLM

20. The US feature in our observations was an hypoechoic irregular and heterogenous ill defined mass and this is similar to the results reported by Han et al.[7] and Lee et al.[2] • Irregular tubular lesions connected to the large • hypoechoic mass were often described. • Rieber et al.[6] reported that MRI does not provide additional information for the differentiation of mastitis from inflammatorycarcinoma • In the Lee et al. study, MRI showed an enhancing of a spiculatedborderslesionwith a benign or intermediary type intensity-time curve. DISCUSSION:IGLM

21. The confirmatory diagnosis is obtained only by fine needle biopsy through the identification of granulomatous inflammation centered on lobules (granulomatouslobulitis) with no caseating necrosis[5]. • In more severe cases, confluency of granulomatous inflammation may obliterate its typical lobulocentric distribution. • Microabscess formation may occasionally involve the entire lobule, as seen in our second case. DISCUSSION: IGLM

22. No consensus exists about the modality of IGLM treatment [3]. • Steroid therapy is often preferred to surgical excision. • Systemic corticosteroid therapy associated with antibiotics is presently the most commonly applied treatment. • Recently, successful results were obtained by topical steroids and this option permits to avoid the side effects of systemic steroid therapy. DISCUSSION: IGLM

23. The secondary forms of granulomatous mastitis were classified by Sabate et al.[3,4] in: Immunilogic disease: Churg-Strauss syndrom, sarcoidosis, Wegener granulomatosis. Inflammatory disease of unknown origin: necrobioticxanthogranulomatosis Specific infection: Mycobacterium Tuberculosis The reaction to a foreign body, described in our third case is a related form. DISCUSSION

24. The granulomatous mastitis is rare if not exceptional. • The imaging means show non specific findings. • The diagnosis is histological, mainly to eliminate inflammatory breast carcinoma. CONCLUSION

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