Granulomatous mastitis (GM) is the most common type of non-lactating breast inflammation, a non-specific inflammatory disease of unknown etiological evidence that occurs in women during the non-lactating period. Granulomatous mastitis has shown a progressive increase in incidence in modern hospital clinical practice and has become of increasing concern in recent years. The disease is prone to recurrent attacks and many patients have had their breasts removed as a result, which seriously affects the quality of life of patients and has a huge impact on the physical and mental health of women.
The diagnosis of granulomatous mastitis requires a comprehensive multidisciplinary analysis combining clinical manifestations, imaging, microbiology and pathological histology. Histopathological examination by hollow-core needle aspiration (CNB) is the main modality and basis for GM diagnosis. Microscopically, the main manifestation is granulomatous inflammation centered on the lobular units of the breast, which may be accompanied by microscopic abscesses; there is a variety of inflammatory cell infiltrates in the lobules, including neutrophils, monocytes, lymphocytes, epithelioid cells and multinucleated giant cells. Neutrophilic foci-microabscesses are common in the middle of the lesion, and occasionally small focal necrosis is seen, forming non-caseating necrotizing granulomas. Tissue immunohistochemistry for IgG4, CD4, and CD8 can be used to assess the sensitivity to hormone therapy.
”This disease is very easily confused with breast cancer, breast tuberculosis, and periductal ductitis, and a clear histopathological diagnosis must be made before treatment”, and the differential diagnosis can be made on the basis of the following points, excluding other diseases.
① non-lactating women with breast lumps, especially with erythema and sinus tract manifestations can be clinically suspected and further examination can be arranged.
(ii) Those who also have elevated leukocytes, rapid sedimentation or elevated CRP and imaging features may be clinically suspected.
(iii) If coupled with biopsy suggestive of characteristic changes in GM and breast tuberculosis can be excluded, a clinical diagnosis can be made.
④If confusion with periductal mastitis or breast tuberculosis is unclear but the former is preferred, “triple anti-mycobacterium drugs” should be given for one month as diagnostic treatment, and then differentiation should be made.
Drug therapy is the basis for surgical treatment
”The treatment of granulomatous mastitis is not static, and after the principles are clarified, an individualized and refined treatment plan should be developed according to each patient’s condition, which is called categorical treatment,” said Prof. Wang Chip, adding that the choice of treatment plan is based on a comprehensive assessment of the condition. According to the cause of the disease, the severity of the disease, the effect of treatment and the extent of lesion involvement, there are hormone-sensitive GM and refractory GM, and according to the clinical manifestations, there are mass GM and GM with abscess.
Steroid hormone therapy is the basic and most important part of the treatment of mass GM. Prednisone 0.75 mg/Kg/d (the dose of other types of systemic glucocorticosteroids is equivalent to the above-mentioned prednisone dose) is administered for at least 6 weeks before surgery, and the dose is gradually reduced until it is discontinued after achieving symptomatic remission, noting that rapid dose reduction may lead to early relapse. Prednisone 30-60 mg/d or methylprednisolone 20-32 mg/d should be given orally for 2 weeks and then reduced by 5-10 mg/week after the lesion is in significant remission, during which time the lesion should be reduced and stabilized to about 50px. Pay attention to drug-related adverse reactions and treat them accordingly, and it is advisable to supplement calcium and vitamin D. For acute inflammation of abscess type GM, some patients have bacterial infection, and antibiotics and other anti-infection treatments should be applied according to the results of bacterial culture and drug sensitivity. In the acute phase (abscess), pus is extracted by puncture, and incision and drainage are not recommended to prevent poor wound healing, and broad-spectrum antibiotics + methicillin are used for 1 to 2 weeks. There is a relationship between granulomatous mastitis and Corynebacterium infection, which can be identified and drug-sensitive experiment can be done in units with conditions, and antibiotic treatment can be selected according to the drug-sensitive results. For those who are unable to carry out drug-sensitivity experiments, clinical trial treatment with amoxicillin can be selected with reference to literature reports. Those with underlying lesions after the inflammation subsides need to be treated with steroid hormone therapy first (the same principles of medication as for the lumpy type).
Some patients with granulomatous mastitis are not well treated with hormonal therapy.
”Not every GM patient’s hormone treatment effect is ideal”, Prof. Wang Chip proposed the definition of refractory granulomatous mastitis: 1.
1. Hormone ineffective: no remission of disease after treatment with the equivalent of prednisone 0.75 mg/kg/d (prednisone 30 mg/d or methylprednisolone 20 mg/d) for more than 2-4 weeks.
2. Hormone dependence.
① Although the disease remission can be maintained, but after 6 weeks of hormone treatment, the dose cannot be reduced to the maintenance dose (prednisone 5mg/d or methylprednisolone 2-4mg/d.
② Relapse within 3 months of discontinuing hormone use.
3, PDM and GM identification difficulties, extensive lesions, not suitable for surgery.
4, GM in one breast and PDM in the other breast, drug therapy is contraindicated. For patients with hormone ineffective or hormone-dependent GM, immunosuppressants such as methotrexate can be added; for those who have difficulty in identifying PDM and GM and have extensive lesions and are not suitable for surgery, or those with rod-shaped bacillus infection can cause refractory GM, some reports can be treated with hormone plus methotrexate, or add antibiotics such as amoxicillin and anti-branched bacillus drugs for 6 months to 1 year to cure and avoid total mastectomy, but should be carefully chosen. For patients with GM in one breast and PDM in the other breast, steroid hormone therapy or anti-branched bacillus drugs should be chosen according to the treatment effect, and attention should be paid to the side effects of drugs during this period.
The aim of surgical treatment is to remove the “core lesion” and reduce the chance of recurrence
”Patients with satisfactory results of drug therapy are still recommended to choose surgical treatment, and refractory cases are not without a knife.”
1. Absolute indications After glucocorticoid treatment, the lesion shrinks to about 50px and is stable.
2.Relative indications Surgery can be considered for patients whose internal treatment is ineffective or/and whose adverse drug reactions have seriously affected the quality of survival.
3. Contraindications GM with acute infection symptoms or in the progressive stage of the disease, extensive GM lesions and large lesion area. For refractory cases that “cannot go under the knife”, Prof. Wang also proposed an effective surgical treatment method: “For refractory cases with poor effect of drug treatment or intolerant to drug side effects, surgical treatment can also be adopted, the key point of which is to remove the lesions one by one and scrape them to the surface connected with the lesions. The point of surgery is to remove the lesions one by one and scrape them to the surface lesions connected to them, which can achieve good results”.
Wrong diet is the biggest killer of disease recurrence
”Several patients experienced rapid recurrence after consuming foods such as bamboo shoots, lychees and beef”. In the prevention of recurrence after granulomatous mastitis, dietary guidance is also crucial, in addition to regular review.
1, dietary guidance Avoid eating foods that have a lactogenic effect and spicy, oily and other foods that are easy on the fire.
2.Regular postoperative review (especially within the first year after surgery), physical examination and imaging examination can help monitor recurrence.
3.Treatment of postoperative recurrence Follow the principles of medication for initial treatment for a new cycle of treatment or surgery.