Clinical study on surgical treatment of granulomatous lobular mastitis

Abstract

Background: The etiology and pathogenesis of granulomatous lobular mastitis (GLM) remain unknown, with no unified evaluation criteria or standard treatments. This study aimed to assess the etiology and features of GLM, as well as the effects of surgery (lesion excision + stage I breast reconstruction; LE + BR) for GLM.

Methods: This study evaluated 178 female GLM patients retrospectively in 2006-2015. The surgery and non-surgery groups included 164 and 14 patients, respectively. All patients received conservative therapy (traditional Chinese medicine combined with regional wet compress and pus drainage). In addition, the surgery group (n=164) underwent LE + BR. Clinical data, including disease course, causes, lesion size, marital status, and treatment approaches, were assessed.

Results: Follow-up was 13-117 months. Seventy-five of the 178 patients had no overt causes (42.1%); meanwhile, 63 (35.4%) and 16 (9.0%) had congenital nipple retraction and a history of psychotropic drugs for >1 year, respectively. The surgery group showed lesions significantly shrunk (≤1 quadrant) with acute inflammation fully controlled; 8 showed recurrence, indicating a cure rate of 95.1% (156/164). In the non-surgery group, 4 cases showed relapse after 6-14 months (cure rate =71.4%; 10/14). Therefore, surgical treatment was significantly more efficient than non-surgical treatment (P=0.001). Kaplan-Meier survival curves for the two treatment types showed a significant difference in recurrence (log rank =11.84, P<0.001).

Conclusions: In GLM patients, LE + BR is safe and effective with respect to cosmetic results, recovery time, and recurrence. Successful surgery should be performed for patients whose lesions ≤1 quadrant, aim to achieve optimal GLM treatment.

Keywords: Conservative therapy; granulomatous lobular mastitis (GLM); intraglandular flap; predisposing factors; surgery.

Figure 1

Clinical appearance of a patient with GLM including skin ulcerations, abscesses and fistulae at her first visit at our hospital. GLM, granulomatous lobular mastitis.

Figure 2

Clinical appearance of a patient with GLM including skin abscesses. GLM, granulomatous lobular mastitis.

Figure 3

Clinical appearance of a patient with GLM including peau d’orange sign (↑). GLM, granulomatous lobular mastitis.

Figure 4

Funnel sign (a hypoechoic, heterogeneous lesion which looks like a pipe with a wide, conical mouth and a narrow stem) is seen in the right breast on ultrasonography in a patient with GLM. GLM, granulomatous lobular mastitis.

Figure 5

Tunnel sign (a hypoechoic lesion which looks like a subcutaneous passway with exit to the skin) in the left breast on ultrasonography in a patient with GLM. GLM, granulomatous lobular mastitis.

Figure 6

Quicksand sign (a hypoechoic, heterogeneous mass which looks like some fine sand lying at the bottom) is seen in the left breast on ultrasonography in a patient with GLM. GLM, granulomatous lobular mastitis.

Figure 7

Case 1. A 26-year-old women with a left GLM after the surgery of lesion (>3 quadrants) excision combined with stage I breast reconstruction with intraglandular flap and fascia flap (LE + BR). (A) Preoperatively, after pus drainages for second times at another clinics; (B) images on MRI showed a whole breast lesion of GLM; (C) in the surgery of lesion excision, nipple areola complex had good blood supply; (D) 2 days after the surgery of stage I breast reconstruction with intraglandular flap and fascia flap; (E) 3 months after the surgery. GLM, granulomatous lobular mastitis.

Figure 8

Kaplan-Meier survival curves for recurrence in the two treatment groups.

Figure 9

The Kaplan-Meier survival curve of the two types of treatment.

Figure 10

Clinical presentation for a 27-year-old woman with GLM at the first visit in our clinic center. The patient underwent 4 times open incision for pus drainage, due to the breast mass with abscess for 3 months. GLM, granulomatous lobular mastitis.

Figure 11

Clinical presentation for a 36-year-old woman with GLM at the first visit in our clinic center. The patient underwent 6 small incisions draining pus due to the right breast mass with abscess for 6 months. GLM, granulomatous lobular mastitis.

Figure 12

Two years after surgery (LE + BR) for a 26-year-old woman. The symmetry of the breast was good.

Figure 13

Three and a half years after the lesion excision combined with stage I breast reconstruction with intraglandular flap and fascia flap for a 32-year-old woman diagnosed with GLM. The appearance of both breasts was with good symmetry. GLM, granulomatous lobular mastitis.

Figure 14

A 29-year-old female with a mass in upper inner quadrant of left breast (A). Seven months after the lesion excision combined with stage I breast reconstruction with intraglandular flap and fascia flap (B).