Granulomatous mastitis including breast tuberculosis and idiopathic lobular granulomatous mastitis

• Published in: Canadian Journal of Surgery Vol. 49; no. 6; pp. 427 - 430
• Main Authors: Bakaris, Sevgi, Yuksel, Murvet, Ciragil, Pinar, Guven, M Atahan, Ezberci, Fibret, Bulbuloglu, Erten
• Format: Journal Article
• Language: English
• Published: Canada CMA Impact Inc 01.12.2006; CMA Impact, Inc; Canadian Medical Association
• Subjects: Adult; Biopsy, Fine-Needle; Breast - pathology; Breast Neoplasms - diagnosis; Breasts; Brief Communication; Diagnosis, Differential; Female; Granuloma - diagnosis; Humans; Inflammatory diseases; Mastitis; Mastitis - diagnosis; Medical diagnosis; Studies; Tuberculosis; Tuberculosis - diagnosis; Ultrasonography, Mammary; Canada
• ISSN: 0008-428X; 1488-2310

Idiopathic lobular granulomatous mastitis (ILGM) is a rare chronic inflammatory disease of the breast that can clinically mimic breast carcinoma.' Patients usually present with progressive onset of a breast lump. The most common clinical presentation is a firm unilateral, discrete breast mass, often associated with an inflammation of the overlying skin. Nipple retraction and even a sinus formation are present.1-3 Regional lymphadenopathy may be present in up to 15% of cases. In more than 50% of reported cases, the initial diagnosis was considered malignant or suspicious for breast carcinoma.4 The diagnosis of ILGM requires that other granulomatous lesions in the breast be excluded (Box 1). Tuberculosis (TB) of the breast is an uncommon disease that is often difficult to differentiate from cancer of the breast when it presents as a lump. Breast TB should be considered in differential diagnosis in people with clinically suspicious breast lumps who are from high-risk populations and/or endemic areas. A 27-year-old woman presented with a 2-month history of a left breast mass. She had a family history of breast cancer affecting her aunt. The patient had a 2-year-old child who had been breast-fed until the onset of the lesion, at which time breast-feeding was discontinued. There was no history of oral contraceptive use. The woman was afebrile, and on physical examination, there was a hard, painful, mobile mass, 3 cm in diameter, in the lower outer quadrant of her left breast. There was nipple discharge and skin retraction. The overlying skin showed signs of inflammation; palpable lymph nodes were present in the ipsilateral axilla. Intraoperatively, the surgeon noticed that the lesion was purulent and thought that it might be an abscess. Findings from cultures of purulent discharge remained sterile. The patient had been treated with multiple broad-spectrum antibiotics for 2 weeks, but the enduration persisted. Two weeks later, the size of the mass remained unchanged. The patient was seen in the casualty department, where an abscess of the breast was initially suspected. Mammography showed a focal asymmetric density associated with architectural distortion, skin thickening and retraction (Fig. 1). Sonographic images showed a hypoechoic lesion with indistinct border. Enlarged axillary lymph nodes were detected on sonography. The mass revealed malignant characteristics. Fine needle aspiration cytology (FNAC) was done on the lump, and granulomatous suppurative lesion was considered. The surgeon performed an excisional biopsy because the mass revealed highly malignant characteristics. The pathology of the lump showed areas of suppuration with microabscess and scattered granuloma. There were no signs of malignancy. After this report, detailed investigations were performed to determine the etiology of the lump. All microbiology tests were negative, and serological and hematological investigations were normal; the PCR test result for mycobacterium was also negative. A diagnosis of idiopathic lobular granulomatous mastitis was made. After treatment, the patient remained in good health, and there was no recurrence of breast lump after 5 years of follow-up. A 38-year-old woman had a 1-month history of a right tender breast lump. The patient had no history of breast trauma or oral contraceptive use, and she had no family history of breast disease. She had 3 children, the youngest being 8 years old; all of them were breast-fed. On physical examination, there was a 7-cm mass in the inner (medial) central portion of the right breast, with induration of the overlying skin. The palpable lymph nodes were present in the ipsilateral axilla. Mammography revealed increased asymmetric density with no definite margins in a large volume of the right breast tissue, with thickening of the overlying skin (Fig. 3). Breast ultrasonographic examination showed increased echogenicity of the right side, compared with the left, with multiple hypoechoic areas. Several enlarged axillary lymph nodes were seen. Radiological examination showed a picture similar to that of an inflammatory breast carcinoma. FNAC was done on the lump, and cytological findings were consistent with a granulomatous inflammatory lesion. In this patient, the main histological feature was granulomatous inflammatory response centred on breast lobules, which confirmed the diagnosis of GM. On further investigation, we found no specific explanation of the etiology of the GM. PCR test results for mycobacterium were also negative.