A Breast Care Conundrum - UNC Radiology

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.



• Mimickers 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.



• Mimickers 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 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 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


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


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.


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



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


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


• 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


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.

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A Breast Care Conundrum - UNC Radiology

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