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 N
USG
MMG
MRI
Schelfout et al.
2001 1
Asymmetric diffuse increased
density
Focal irregular homogeneously
enhanced masses
Van Ongeval et al.
1997
Inhomogeneous hypoechoic lesion with posterior acoustic shadow
Bilateral diffuse increased density of
the fibroglandular tissue
An irregular ring-shaped enhanced
lesion
Cakir et al.
2002
Inhomogeneous hypoechoic lesion
with posterior acoustic shadow
Unilateral diffuse increased density
Heterogeneously enhanced irregular
lesion and gradual and progressive
enhancement without washout
Sakurai et al.
Irregularly enhanced mass without
contrast washout
Memis et al. 15
Irregular hypoechoic mass with
tubular extensions
Asymmetric opacities
Kara et al.
2003
Well-defined hypoechoic areas with
Asymmetric densities with skin
thickening
Engin et al
1999 10
Heterogeneous hypoechoic masses,
circumscribed opacities,
and abscess cavities with sinus
tracts
Circumscribed opacities asymmetric dense parenchyma,
nodular opacities
parenchymal distortion ,
and bilateral dense parenchyma
Yilmaz et al 12
Heterogeneous hypoechoic areas
with/without tubular extensions, hypoechoic irregular mass, and edematous breast with
skin thickening
Focal asymmetric density without
mass formation, irregular
masses, and negative
Han et al 9
Tubular hypoechoic lesions
and oval hypoechoic masses with
hypoechoic tubular connections
Multiple small ill-defined masses and local asymmetric
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 Low power view High 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
Short course high dose prednisolone
Single patient case report
Short follow up period
Recurrence was not reported
Azlina et al. World J Surg
25 patients with mean follow up of 6.5 months
Recurrence up to 50% for steroid treatment

23. Conservative Management
Lai et al. Breast Journal
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 MASTITIS EXPERIENCE 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. This study is aimed to determine the best treatment modality for IGM
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 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 6 26 9 3 39 13 1 4.3 No. of cases Percentage
Psychiatric illness
schizophrenic 6 26
Drug/ Hormonal Rx
contraceptives
antipsychotics 9 3 39 13
Diabetes Mellitus 1
4.3

32. Drug 6 1 2 26 3 13 No. of cases Percentage Antipsychotics Flupenthixol
Thioridazine
Promethazine
Sulperide
Trifluroperazine 6 1 2 26
Hormonal Rx
Primulut
Premarin 3 13

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
Surgery
Expectant
P value *
(P< 0.05)
Age (mean)
40.42 (7.50)
39.55 (11.10)
0.928
Duration of follow up (mean)
28.80 (23.06)
15.3 (12.95)
0.126
Recurrence (%) 15
4.5
0.976
Static disease
7.5%
4.5%
Brackets = Standard deviation
*Mann-Whitney U test

37. Recurrent/ static cases
Patient
number
Age
Drug history
Presentation
Duration of follow up
Treatment
Final Outcome 1 30
Sterile abscess 15
Incision and drainage
Regressed 2 39
Sulpiride 60
regressed 3 35 24
Static 4 47
Premarin
Promethazine
Mass 48
Expectant 5 44 12
static

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

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