SEMIOLOGY AND DIFFERENT CAUSES

OF GRANULOMATOUS MASTITIS

A. SAIDANE, N. DALI, I. MARZOUK, A. FENNIRA, A. MANAMANI, L. BEN FARHAT, L. HENDAOUI

Radiology department, Mongi Slim Hospital of Marsa, Tunis

INTRODUCTION Granulomatous mastitis is a rare begnin

imflammatory breast disease that mostly occurs in women of childbearing age.

The main diagnosis difficulty is that it can clinically and radiologically mimic an inflammatory breast carcinoma.

Idiopathic form has to be distingueshed from those secondary to infections and other causes

MATERIALS & METHODS

We report the cases of 3 patients whose age ranges between 45 and 59 years.

They were all explored by mammography, ultrasonography and percutanous biopsy.

The histological examination confirmed the diagnosis

RESULTS: CASE 1 A 53 years old women.

No medical history.

Progressively worsening inflammatory lump of the left breast with skin ulceration and induration.

RESULTS: CASE 1

MAMMOGRAPHY: ill-defined opacity of the upper outer quadrant

nipple retraction

skin thickening

round macrocalcification

hypoechoic spiculated tissular lesion with posterior

shadowing associated to linear hypoechoic band joining the skin (arrow)

RESULTS: CASE 1

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 2 A 45 years old women with no medical

history.

Adressed for an inflammatory induration of the left breast

The physical examination revealed an entire hyperemic, edematous, firm and painful left breast with multiple fistulous orifices on the skin letting out a purulent discharge

RESULTS: CASE 2

Diffuse density increase Skin thickening

No architectural distorsion Raound calcifications

RESULTS: CASE 2

Posterior shadowing

Hypoechoic heterogenous and ill-defined mass

Hypoechoic linear band indicating a fistulous path

Intramammary lymph node

RESULTS: CASE 2 HISTOLOGY:

Many inflammatory granulomatous foci including the lobules and made of lymphocytes, plasmocytes, histiocytes and epithelial cells. 

There were also micro-abscesses

IDIOPATHIC GRANULOMATOUS MASTITIS

RESULTS: CASE 3

A 59 years old women.

Fibroadenoma of the left breast, operated 5 years ago. 

Iterative mammographic and ultrasonographic controls

RESULTS: CASE 3

intra mammary lymph nodes ( )

Density increase in the upper outer quadrant ( )

Axillary lymph node ( )

Skin thickening ( )

RESULTS: CASE 3

Intra mammary lymph node

Hypoechoic mass with irregular borders

RESULTS: CASE 3HISTOLOGY:

Granulomatous reaction made of giant and epithelioid cells surrouding a foreign body (suture thread)

SECONDARY GRANULOMATOUS MASTITIS

DISCUSSION The granulomatous mastitis has to be differenciated in two forms:

the idiopathic form is named Idiopathic Granulomatous Lobular Mastitis (IGLM)

the secondary forms are caused by otheretiologies of chronic inflammatory breast diseases,such as plasma cell mastitis, Wegener’sgranulomatosis, ruptured cyst, sarcoidosis,fat necrosis, tuberculosis, carcinoma,duct ectasia, and fungal infection [1]

DISCUSSION: IGLM The IGLM was first described in 1972 by Kessler and Wolloch [1,3].

It occurs mainly in women of childbearing age, especially at the third decade and it’s frequentlyassociated with recent childbirth (ranging from 2months 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 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 oralcontraceptive use. However, no true associations withpregnancy, breast-feeding, prolactin levels, or oral contraceptive use have been established to date [5]

The mammographic findings are not specific.

DISCUSSION:IGLM 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 irregular ill-definedmass to be the most common finding, skin thickening was observed in more than 60% of the cases and benign-looking axillary lymph node in nearly 55%, which is confirmed by our 2 cases.

The lesions are usually unilateral and can affect any quadrant except the subareolar region which is an exceptionnal location[2]

DISCUSSION:IGLMThe 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 inflammatory carcinoma

In the Lee et al. study, MRI showed an enhancing of a spiculated borders lesion with a benign or intermediary type intensity-time curve.

DISCUSSION: IGLM The confirmatory diagnosis is obtained only by fine needle biopsy through the identification of granulomatous inflammation centered on lobules (granulomatous lobulitis) 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 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.

DISCUSSIONThe secondary forms of granulomatous mastitis were classified by Sabate et al.[3,4] in:

1. Immunilogic disease: Churg-Strauss syndrom, sarcoidosis, Wegener granulomatosis.

2. Inflammatory disease of unknown origin: necrobiotic xanthogranulomatosis

3. Specific infection: Mycobacterium Tuberculosis

The reaction to a foreign body, described in our third case is a related form.

CONCLUSION 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.

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2. Lee JH, Oh KK, Kim EK, Kwack KS, Jung WH, Lee HK. Radiologic and clinical features of idiopathic granulomatous lobular mastitis mimicking advanced breast cancer. Yonsei Med J 2006; 47:78–84

3. Altintoprak F. Korean j intern med 2011;26:356-359

4. Sabaté JM, Clotet M, Gomez A et al. Radiologic evaluation of uncommon inflammatory and reactive breast disorders. Radiographics 2005; 25: 411-24

5. Tuli R, O'Hara B, Hines J, Rosenberg A. Idiopathic granulomatous mastitis masquerading as carcinoma of the breast: a case report and review of the literature. International Seminars in Surgical Oncology 2007, 4:21

6. Rieber A, Tomczak RJ, Mergo PJ, Wenzel V, Zeitler H, Brambs HJ. MRI of the breast in the differential diagnosis of mastitis versus inflammatory carcinoma and follow-up. J Comput Assist Tomogr 1997;21:128-32

7. Han BK, Choe YH, Park JM, et al. Granulomatous mastitis: mammographic and sonographic appearances. AJR 1999; 173:317–320