Post on 17-Feb-2022
transcript
Granulomatous MastitisA Breast Care Conundrum
Femi-Abodunde A, Agrawal Y, Ellis J, Lee SS, Jordan SG
University of North Carolina School of Medicine
Department of Radiology
Chapel Hill, North Carolina
Disclosures
Abiola Femi-Abodunde, MD: Nothing to disclose
Yash Agrawal: Nothing to disclose
Joshua Ellis: Nothing to disclose
Sheila Lee, MD: Nothing to disclose
Sheryl Jordan, MD: Nothing to disclose
Granulomatous Mastitis (GM)
This exhibit educates radiologists and trainees on
• Mimickers of GM
• Key clinical findings and pathophysiology to assist in accurate diagnosis
• Unique challenges in the management and surveillance of GM
• Puerperal/Non-puerperal mastitis
• Inflammatory breast cancer
• Sarcoidosis
• Sclerosing lymphocytic lobulitis(Diabetic mastopathy)
• Tuberculous mastitis
• Wegener’s granulomatosis
There are overlapping imaging features between GM and the above
diseases, contributing to its diagnostic challenge.
Granulomatous Mastitis (GM)
This exhibit educates radiologists and trainees on
• Mimickers of GM
• Key clinical findings and pathophysiology to assist in accurate diagnosis
• Unique challenges in the management and surveillance of GM
• Palpable mass 1-20 cm
• Pain
• Erythema
• Breast enlargement (usu unilateral but may be bilateral)
• Fluid collections and fistulae
• Adenopathy (usu unilateral)
Visual inspection is key in assuring radiologists contribute to patient
care in most meaningful and accurate manner.
Granulomatous Mastitis (GM)
This exhibit educates radiologists and trainees on
• Mimickers of GM
• Key clinical findings and pathophysiology to assist in accurate diagnosis
• Unique challenges in the management and surveillance of GM
• Little or no inter-specialty consensus on management and surveillance
• Underrepresented diagnosis in ACR BI-RADS® Atlas 5th edition
• Distinctive appearance and presentation of GM frequently not known to providers
• Patient herself frequently not known to providers
Education of providers is key!
GM Classic Patients: Dear Dr, I have…
Breast Pain and Tenderness
Breast Redness
Palpable mass
• Granulomatous mastitis (GM) is a chronic inflammatory breast disease of unknown prevalence, first described by Kessler and Wolloch in 1972
• Demographics have been shown to be parous premenopausal women with history of lactation. Strong reported associations with pregnancy, lactation, hyperprolactinemia
• There have been case studies reporting male occurrence
GM: The Basics
Breast Pain and Tenderness
Breast Redness
Palpable mass
• In some studies, large subset of patients reported 3-36 month nursing duration with GM occurring 6 months-2 years post cessation of breast feeding
• Statistically insignificant association between non-lactating breast and GM in patients with exclusive unilateral breast feeding suggesting Mammary Duct-Associated Inflammatory Disease Sequence (MD-AIDS)
GM: Lactation
Breast Pain and Tenderness
Breast Redness
Palpable mass
• GM has been theorized to occur secondary to local granulomatous response to an injured ductal epithelium.
• On H&E, infiltrating granulomas, composed of neutrophils.
GM: Pathophysiology
Source: http://www.radiologyassistant.nl/en/p4793bfde0ed53/breast-calcifications-differential-diagnosis.html
Image provided by Dr. Benjamin Calhoun, UNC
GM: Imaging Mammography
Image provided by Dr. Benjamin Calhoun, UNC
Induration and tenderness
overlying the left upper outer
quadrant with pink nipple
discharge. Healed scar
above the areola from prior
incision & drainage (I&D)
Left CC mammogram demonstrating
ill-defined focal asymmetry in the
upper outer breast
Spot compression magnification
view shows persistent asymmetry
Ultrasound-guided biopsy of an ill-
defined hypoechoic mass with
suggestion of skin tract. Path=GM
GM: Imaging Ultrasound
Image provided by Dr. Benjamin Calhoun, UNC
Fistulae x 2 from prior
core needle biopsy
(Path=GM)
6 months earlier
Multi-site right breast peri-
areolar discoloration and
scarring from previous
surgical I&D
Expanded field of view ultrasound of the 7-10:00 right breast
demonstrates several irregular hypoechoic masses, diffuse
architectural distortion, and cutaneous fistula formation
Targeted ultrasound of the right breast
upper outer quadrant demonstrates an
irregular angulated hypoechoic mass
Source: Nissman D, Birchard K, Huang B, Lee E (Eds). Emergency and Trauma Radiology: A Teaching File. Wolters Kluwer, 2016.
Image provided by Dr. Benjamin Calhoun, UNC
GM: Imaging Magnetic Resonance
Sagittal T1-weighted imaging with fat
saturation indicating a 1 cm mass in
the right breast inferiorly
Sagittal post-contrast T1-weighted
imaging with fat saturation indicating
enhancing 1 cm mass
Thereafter, MR-guided
core needle biopsy
(Path=GM)
Mammography
Ultrasonography
MRI
Focal or global
asymmetry
Irregular
mass(es)
Normal
findings
Skin thickening Irregular
hypoechoic
mass(es)
Circumscribed
hypoechoic
mass(es)
Abscess +/-
sinus tract
T2
hyperintensity
Rim
enhancing
Contrast
enhancement
with variable
kinetics
GM: Imaging Summary
• GM is relapsing disease that frequently leads to patients undergoing multiple procedures that may lead to adverse effects including, but not limited to, non-healing sinus tracts
• GM underrepresented diagnosis in ACR BI-RADS® Atlas
• No formal interdisciplinary consensus on treatment algorithm for GM
• Institution/practice dependent
GM: The Clinical Conundrum
University Of Southern California
GM: Helpful Algorithms in Rad Literature
University Of Southern California University Of Texas Health At San Antonio
Hovanessian Larsen et al. AJR 2009
Pluguez-Turull et al. Radiographics 2018
GM: The Clinical Conundrum
University Of Southern California
In 811 pages of BI-RADS ® Atlas:
1 description of “chronic granulomatous abscess”
1 description of “granulomatous mastitis”
Isolated to captions of figures in the Ultrasound section
The text itself is devoid of descriptions of GM
University Of Southern California
In 811 pages of BI-RADS ®:
1 description of “chronic granulomatous abscess”
1 description of “granulomatous mastitis”
Isolated to captions of figures in the Ultrasound section
The text itself is devoid of descriptions of GM
Further, the Atlas does not offer GM as a PATHOLOGY
CODE in DATA DICTIONARY, with latter a key guide
practices use in reporting their federally-mandated required
audits
GM is not listed or described in the Mammography or MR
sections of the Atlas, in any published revision, or as a
Special Case in the Ultrasound section
GM: The Clinical Conundrum
• No formal interdisciplinary consensus on treatment algorithm
• Due to the rarity and self-limiting course of disease, two different treatment approaches have been proposed and validated across the surgical and radiographic literature
• Surgical literature concludes that GM is associated with localized infection and requires antibiotics and surgical drainage, with no role for corticosteroids.
• Breast clinic literature concludes that corticosteroids help patients enter remission quicker and advocate for the use of corticosteroids as temporizing therapy.
GM: Interdisciplinary Disagreement
University Of Southern California
Surgery
• Seminal article is Kok et al which advocates initial approach by surgeons.
• In their study of 43 patients, 93% underwent surgical procedure as the main treatment (excision or incision and drainage).
• Recurrence rate 23%
Breast Clinic
GM: Interdisciplinary Disagreement
• Pandey et al strongly advocate for corticosteroids and short interval follow up prior to any consideration for surgery.
• In their study of 49 patients, 90% were treated with oral steroids.
• Complete resolution rate 80%
Case 1A 37 year old Latino female
G4P3013, hx of DM presents to the
Emergency Department with a 2
week history of left breast pain and
acute onset of bloody discharge.
Denies any recent trauma or
constitutional symptoms.
On physical exam tenderness to
palpation on lateral inferior left
breast. No warmth, swelling or
erythema. No palpable lymph
nodes. Ultrasound was obtained.
Patient discharged home with
referral to UNC breast surgical
clinic for further evaluation.
A diagnostic mammogram was
requested.
MLO view of
the left breast
demonstrating
peri-areolar
and areolar
skin
thickening. No
suspicious
masses or
asymmetry on
magnified
views (right).
Assessment:
BIRADS 4A
Targeted ultrasound of the lateral inferior breast demonstrates
heterogenous echogenicity with irregular hypoechoic mass and
architectural distortion measuring 2.7 cm (left) with no definite fluid
collection or flow on doppler (right). Assessment: BIRADS 3
Core Needle Biopsy
confirmed GM
Teaching Point #1:
Clinical and imaging features are often non-specific
and require histopathological diagnosis of the
granulomas comprised of neutrophils.
Case 2A 45 year old female presents to the
Emergency department with a
progressively enlarging and painful
right breast mass with a sensation that
‘her breast might pop’. Denies any
recent trauma or constitutional
symptoms.
Mammogram
asymmetry
Targeted
ultrasound
demonstrates
irregular non-
circumscribed 3.3
mass with
heterogenous
echotexture
favored to
represent an
abscess. BIRADS
2. Patient
underwent an
ultrasound guided
core needle biopsy
No organisms seen on
H & E. GM was
subsequently diagnosed
Ultrasound was obtained.
Previous imaging findings were
inconclusive and she seeks a second
opinion because of persistent
symptoms.
On physical exam, erythema and
warmth in 3-4 o’clock position.
Underlying irregular mass. Exquisite
tenderness to palpation. No palpable
lymph nodes.
Teaching Point #2:
GM overlaps with infectious mastitis. This can yield
delays in diagnosis and treatment if not considered.
Biopsy and/or steroids may be delayed.
Case 3A 65 year old Latino female
presents to rural health clinic with
progressively enlarging left breast
mass and progressive unilateral
nipple retraction. Denies any
recent trauma or constitutional
symptoms.
LMLO
mammogram with
increased density
in the retro-areolar
region, nipple
retraction and skin
thickening with an
irregular mass. 2
cm enlarged
axillary lymph
node seen
US with Irregular not
circumscribed hypoechoic
shadowing mass
Assessment BIRADS 5
Image provided by Dr. Benjamin
Calhoun, UNC
On physical exam, there is peri-
areolar erythema, nipple
inversion and a centrally located
5x5 cm firm mass.
Mammogram and ultrasound
were obtained, followed by CNB.
Surg path = Marked acute inflammation with
granulomas, features consistent with cystic
neutrophilic granulomatous
mastitis
Teaching Point #3:
Mass, axillary lymphadenopathy, skin thickening,
and nipple retraction are common in GM and
imitate cancer. This may result in overestimation of
malignancy risk by radiologists.
Case 4
Biopsy-confirmed
Granulomatous MastitisRMLO view indicating low-
density mass in the middle
depth at the area of palpable
concern, with predominantly
obscured margins
Targeted ultrasound with
indeterminate irregular shaped solid
hypoechoic mass at the area of
palpable concern. Assessment
BIRADS 5
A 39 year old Latino female
referred from rural health clinic
with a 6 month history
progressively enlarging right
breast mass and pain, recently
biopsied complicated by sinus
tract formation.
PMH remarkable for breast prior
I&Ds
Scarring x 2 from prior I&Ds
Teaching Point #4:
Poor provider awareness and multiple providers
(ER and rural health clinic) may yield varied
treatment regimens and several incision &
drainage or biopsy breast procedures.
Our preliminary findings
University Of Southern CaliforniaTotal Patients In Our UNC
Biopsy-proven GM Cohort
65
Mean Age at Diagnosis
37.8 years (21-67)
62% are of Latino Ethnicity Predilection for
ethnic minorities
GRANULOMATOUS
MASTITIS
Latina women are disproportionately
affected.
Clinical & imaging features are similar to
other conditions, including malignancy. Core needle
biopsy is indicated.
Enhancing provider awareness is key to
establishing a formalized surveillance and
treatment algorithm
Chronic inflammatory disease that is a histopathologic
diagnosis
References
Kessler E, Wolloch Y. Granulomatous mastitis: a lesion clinically simulating carcinoma. Am J Clin Pathol1972;58(6):642–646.
Altintoprak F, Karakece E, Kivilcim T, et al. Idiopathic granulomatous mastitis: an autoimmune disease? Sci World J 2013;2013:148727.
Pandey TS, Mackinnon JC, Bressler L, Millar A, Marcus EE, Ganschow PS. Idiopathic granulomatous mastitis: a prospective study of 49 women and treatment outcomes with steroid therapy. Breast J 2014;20(3):258–266.
Hovanessian Larsen LJ, Peyvandi B, Klipfel N, Grant E, Iyengar G. Granulomatous lobular mastitis: imaging, diagnosis, and treatment. AJR Am J Roentgenol. 2009;193(2):574–581
Pluguez-Turull, Cedric W., et al. "Idiopathic Granulomatous Mastitis: Manifestations at Multimodality Imaging and Pitfalls." RadioGraphics 38.2 (2018): 330-356.
Gautier, N., Lalonde, L., Tran-Thanh, D., El Khoury, M., David, J., Labelle, M., et al. (2013). Chronic granulomatous mastitis: Imaging, pathology and management. European Journal of Radiology, 82(4), e165-75. doi:10.1016/j.ejrad.2012.11.010
References
Nissman D, Birchard K, Huang B, Lee E (Eds). Emergency and Trauma Radiology: A Teaching File. Wolters Kluwer, 2016.
Smithuis R, Pijnappel R [Digital Image]. Radiology Assistant 2008. Web. October 17, 2018. Retrieved from http://www.radiologyassistant.nl/en/p4793bfde0ed53/breast-calcifications-differential-diagnosis.html
D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA et al. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology; 2013
Ellis J, Vakharia A, Jordan S. BI-RADS, Quality Improvement, and Granulomatous Mastitis: Searching for a Crossroads. American College of Radiology. ACR 2017 Annual Meeting Abstracts and ePosters
Reddy KM, Meyer CE, Nakdjevani A, Shrotria S. Idiopathic granulomatous mastitis in the male breast. Breast J 2005;11(1):73
Al Manasra AR, Al-Hurani MF. Granulomatous mastitis: a rare cause of male breast lump. Case Rep Oncol2016;9(2):516–519
Freeman, C. M., Xia, B. T., Wilson, G. C., Lewis, J. D., Khan, S., Lee, S. J., et al. (2017). Idiopathic granulomatous mastitis: A diagnostic and therapeutic challenge. American Journal of Surgery, 214(4), 701-706. doi:S0002-9610(17)30150-2
Kok, K. Y. Y., and P. U. Telisinghe. "Granulomatous mastitis: presentation, treatment and outcome in 43 patients." The surgeon 8.4 (2010): 197-201.
Contact Information
All questions & queries can be directed to
abiola.femi-abodunde@unchealth.unc.edu