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SEMIOLOGY AND DIFFERENT CAUSES OF GRANULOMATOUS MASTITIS

SEMIOLOGY AND DIFFERENT CAUSES OF GRANULOMATOUS MASTITIS

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SEMIOLOGY AND DIFFERENT CAUSES OF GRANULOMATOUS MASTITIS

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  1. SEMIOLOGY AND DIFFERENT CAUSES OF GRANULOMATOUS MASTITIS A. SAIDANE, N. DALI, I. MARZOUK, A. FENNIRA, A. MANAMANI, L. BEN FARHAT, L. HENDAOUI Radiologydepartment, MongiSlimHospital of Marsa, Tunis

  2. Granulomatousmastitisis a rare begninimflammatorybreastdiseasethatmostlyoccurs in women of childbearingage. • The main diagnosisdifficultyisthatitcanclinically and radiologicallymimic an inflammatorybreastcarcinoma. • Idiopathicform has to bedistingueshedfromthosesecondary to infections and other causes INTRODUCTION

  3. We report the cases of 3 patients whoseage ranges between 45 and 59 years. • Theywere all explored by mammography, ultrasonography and percutanousbiopsy. • The histologicalexaminationconfirmed the diagnosis MATERIALS & METHODS

  4. A 53 yearsoldwomen. • No medicalhistory. • Progressivelyworseninginflammatory lump of the leftbreastwith skin ulceration and induration. RESULTS: CASE 1

  5. MAMMOGRAPHY: • ill-definedopacity of the upperouter quadrant • nippleretraction • skin thickening • round macrocalcification RESULTS: CASE 1

  6. hypoechoicspiculatedtissularlesionwithposteriorshadowingassociated to linearhypoechoic band joining the skin (arrow)

  7. 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 1

  8. A 45 yearsoldwomenwithno medical history. • Adressed for an inflammatory induration of the leftbreast • The physicalexaminationrevealed an entirehyperemic, edematous, firm and painfulleftbreastwith multiple fistulous orifices on the skin letting out a purulent discharge RESULTS: CASE 2

  9. Diffuse densityincrease RESULTS: CASE 2 • Skin thickening • No architectural distorsion • Raound calcifications

  10. Hypoechoicheterogenous and ill-defined mass Hypoechoic linear band indicating a fistulous path Posteriorshadowing RESULTS: CASE 2 Intramammarylymphnode

  11. HISTOLOGY: • Manyinflammatorygranulomatousfociincluding the lobules and made of lymphocytes, plasmocytes, histiocytes and epithelialcells.  • There werealso micro-abscesses IDIOPATHIC GRANULOMATOUS MASTITIS RESULTS: CASE 2

  12. A 59 yearsoldwomen. • Fibroadenoma of the leftbreast, operated 5 yearsago.  • Iterativemammographic and ultrasonographiccontrols RESULTS: CASE 3

  13. intra mammary lymph nodes ( ) Densityincrease in the upperouter quadrant ( ) Axillarylymphnode ( ) RESULTS: CASE 3 Skin thickening ( )

  14. Hypoechoic mass withirregularborders RESULTS: CASE 3 Intra mammarylymphnode

  15. HISTOLOGY: Granulomatousreaction made of giant and epithelioidcellssurrouding a foreign body (suture thread) SECONDARY GRANULOMATOUS MASTITIS RESULTS: CASE 3

  16. The granulomatousmastitis has to bedifferenciated in twoforms: • the idiopathicformisnamedIdiopathicGranulomatousLobularMastitis (IGLM) • the secondaryforms are caused by other • etiologies of chronic inflammatory breast diseases, • such as plasma cell mastitis, Wegener’s • granulomatosis, rupturedcyst, sarcoidosis, • fat necrosis, tuberculosis, carcinoma, • duct ectasia, and fungal infection [1] DISCUSSION

  17. The IGLM was first described in 1972 by Kessler and Wolloch [1,3]. • It occursmainly in women of childbearingage, especiallyat the thirddecade and it’sfrequently • associated with recent childbirth (ranging from 2 • months 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

  18. 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 oral • contraceptive use. However, no true associations with • pregnancy, breast-feeding, prolactin levels, or oral contraceptive use have been established to date [5] • The mammographic findings are not specific. DISCUSSION:IGLM

  19. 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 irregularill-defined • mass to be the most common finding, skin thickening was observed in more than 60% of the cases and benign-lookingaxillarylymphnode in nearly 55%, whichisconfirmed by our 2 cases. • The lesions are usuallyunilateral and can affect any quadrant except the subareolarregionwhichis an exceptionnal location[2] DISCUSSION:IGLM

  20. The 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 inflammatorycarcinoma • In the Lee et al. study, MRI showed an enhancing of a spiculatedborderslesionwith a benign or intermediary type intensity-time curve. DISCUSSION:IGLM

  21. The confirmatory diagnosis is obtained only by fine needle biopsy through the identification of granulomatous inflammation centered on lobules (granulomatouslobulitis) 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

  22. 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. DISCUSSION: IGLM

  23. The secondary forms of granulomatous mastitis were classified by Sabate et al.[3,4] in: Immunilogic disease: Churg-Strauss syndrom, sarcoidosis, Wegener granulomatosis. Inflammatory disease of unknown origin: necrobioticxanthogranulomatosis Specific infection: Mycobacterium Tuberculosis The reaction to a foreign body, described in our third case is a related form. DISCUSSION

  24. 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. CONCLUSION

  25. Hovanessian Larsen L, Peyvandi B, Klipfel N, Grant E, Iyengar G.GranulomatousLobularMastitis: Imaging, Diagnosis, and Treatment . AJR 2009; 193: 574-581 Lee JH, Oh KK, Kim EK, Kwack KS, Jung WH, Lee HK. Radiologic and clinical features of idiopathic granulomatouslobularmastitismimickingadvanced breast cancer. Yonsei Med J 2006; 47:78–84 Altintoprak F. Korean j intern med 2011;26:356-359 Sabaté JM, Clotet M, Gomez A et al. Radiologicevaluation of uncommoninflammatory and reactivebreastdisorders. Radiographics 2005; 25: 411-24 Tuli R, O'Hara B, Hines J, Rosenberg A. Idiopathicgranulomatousmastitismasquerading as carcinoma of the breast: a case report and review of the literature. International Seminars in Surgical Oncology 2007, 4:21 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 Tomogr1997;21:128-32 Han BK, Choe YH, Park JM, et al. Granulomatousmastitis: mammographic and sonographicappearances. AJR 1999; 173:317–320 REFERENCES