Roberto N. Gonzales Jr. MD.

Edgardo Penserga, M.D., FPCS, FPSGS

Reynaldo Joson, M.D., MHA, MHPEd, MS Surg

Department of Surgery

Ospital ng Maynila Medical Center

Key words : granulomatous mastitis

Reprint request : Roberto N. Gonzales Jr. M.D.

Department of Surgery, Ospital ng Maynila Medical Center

OMMC Surgery@yahoogroups.com

Abstract

A 28 y/o female Filipino patient presented with  a 2 x 2 cm palpable mass on the upper outer quadrant of her left breast which enlarged dramatically to 4 x 5 cm for the span of 3 weeks. Fine needle aspiration cytolology was done and had been considered highly suspicious for carcinoma. Initial diagnosis was breast carcinoma and was planned to undergo a modified radical mastectomy. But upon subsequent evaluation and work ups. The breast lesion was confirmed to be a granulomatous mastitis hence planed MRM was withdrawn. Patient underwent 6 months of anti koch’s medication and subsequently improved. Discussion centered on Granulomatous Mastitis a very rare lesion of the brest which mimics breast carcinoma.

Introduction

Granulomatous lobular mastitis is a rare disease primarily affecting young women, most often during pregnancy and/or lactation. This entity was first described by Kessler and Wolloch in 1972 and further elaborated by Cohen in 1977.¹ Approximately 55 cases have been described in the English literature, but many pathologists and clinicians are still unaware of the disease. It is characterized by chronic, non-caseating granulomatous lobulitis of unknown etiology. Failure to recognize granulomatous mastitis, which may be consequently mistaken for breast carcinoma, has previously resulted in unnecessary mastectomies or open biopsies.

            This is a case report of a female Filipino patient who was initially assessed to have breast carcinoma but on further work-up was found to have a granulomatous mastitis.

            This case report is made to develop the awareness on granulomatous mastitis

CASE REPORT

The patient, a 28-year-old woman, had been aware of a tender left breast mass for 2 months. She had first consulted Ospital ng Maynila Medical center surgery out patient department, where the results of fine needle aspiration cytology had been considered highly suspicious for carcinoma. There was  past history of tuberculosis, and chest x-ray was positive for pulmonary tuberculosis. The patient was gravida 1, para 1. Her last child had been delivered 2 years prior to admission, and had been breast-fed for 5 months.                                                                                        

Initial physical examination revealed a 2 x 2 cm² hard mass in the upper mid-lateral portion of the left breast. Axillary lymph nodes were not palpable. The tumor enlarged rapidly and measured 4 x 5 cm² within 3 weeks prior to admission. There was erythema and crust like induration over the skin.  Review of the initial aspirate  revealed clusters of atypical cells with large nuclei and a moderate N/C ratio. Slight nuclear hyperchromasia and small nucleoli were also seen. Since our clinical diagnosis was stage IIIA breast cancer, the initial plan was to do modified radical masrectomy. However upon further evaluation and review of slides for cytology. The inflammatory infiltrate included polymorphonuclear leukocytes, plasma cells, epithelioid cells and Langhans-type giant cells in the granuloma. There was  evidence of tubercle formation with caseous necrosis. (see figures 1 and 2). The axillary lymph nodes were not pathologically affected by the granulomatous change. The final diagnosis was idiopathic granulomatous mastitis, and the patient was informed that there was no malignant breast disease. Patient underwent 6 months of anti koch’s medication and subsequently improved.

DISCUSSION

Granulomatous mastitis is a rare, chronic, noncaseating, granulomatous lobulitis of uncertain etiology. Clinically, it mimics breast cancer and is frequently mistaken for a malignancy, particularly if the regional lymph nodes are enlarged.Thus, failure to diagnose it may result in unnecessary mastectomies. The lesions of IGM are usually unilateral and can occur in any of the 4 quadrants. The condition has been known to occur in both breasts. The clinical findings and mammographic results of IGM are often similar to those of a carcinoma. As a result, a granulomatous reaction in a carcinoma remains a critically important differential diagnosis for exclusion. However, most examples of this unusual complex have areas composed of easily identified intraductal or invasive carcinoma. In rare cases, immunohistochemical stains for cytokeratin or smooth muscle actin may be necessary to identify a carcinoma against this background. Besides mimicking breast carcinoma, other diseases should also be excluded that might cause a granuloma in the breast, such as tuberculosis, syphilis, and histoplasmosis infections, as well as a foreign-body granuloma, vaccination granuloma, mammary duct ectasia, sarcoidosis, Wegener’s granulomatosis, giant cell arteritis, and polyarteritis nodosa.

Histologically, IGM tissue is predominately composed of inflammatory cells, mainly lymphocytes, associated with epithelioid histiocytes admixed with Langhan’s giant cells. Stains for bacterial identification (such as acid-fast stain, Gram stain, and Warthin-Starry stain) and those for fungal demonstration (for example, PAS and GMS stains) are applied to rule out possible infectious granulomas. Bacterial culture, fungal culture, and mycobacterial culture may be helpful but are much more time-consuming and relatively expensive for exclusion of an infectious granuloma. Hence, the term IGM should be adopted for those lesions which demonstrate no specific etiologic agent. Although its etiology is still unknown, several pathogeneses of granulomatous mastitis have been postulated including autoimmune(  and infective processes(3) and a local reaction to chemical secretions.  Associations of IGM with a recent pregnancy, breastfeeding, and oral contraceptives have been reported.

 The treatment of choice for IGM has not yet been established. Prior to 1980, because of the clinical impression of a possible malignancy, surgical excision of the entire lesion was suggested. Complications seem to be related to both the disease process and the surgical procedure and include skin ulceration, abscess formation, fistulae, wound infection, and recurrence. Some patients had relapses in the form of chronic mastitis after excisional biopsies.  Two decades ago, DeHertogh suggested complete resection or open biopsy with 60 mg/kg/day prednisolone therapy for treatment of granulomatous mastitis. Several other reports of using 60 mg/kg/day prednisolone to treat IGM have also been published. With our patient, in view of her history of gestational diabetes, a conservative dosage of 30 m/day prednisolone (0.6 mg/kg/day) was initiated with periodic blood sugar monitoring. However, her granulomatous mastitis recurred 11 weeks after the initial treatment. Prednisolone at 40 mg/day (0.8 mg/kg/day) for 4 weeks was then administered with a successful result. Her blood sugar was controlled well through her diet. Herein, we report a case of idiopathic granulomatous mastitis successfully treated with 40 mg/day (0.8 mg/kg/day) prednisolone. As the administration of a steroid can cause some severe adverse effects, such as opportunistic infections, dermatological manifestations, hypertension, peptic ulcer disease, neuropsychiatric symptoms, hyperglycemia, myopa thy, and osteoporosis, we feel that the minimum dose of a steroid should be recommended. The duration and recommended dosage of steroid treatment deserve further clinical research to establish an adequate treatment regimen.