Granulomatous Mastitis – Inflammatory Breast Lesion Clinically Mistaken for Malignancy in Younger Women

Granulomatous mastitis (GM) is a rare chronic inflammatory disease of the breast that can clinically mimic breast carcinoma.¹ The ladies usually present with progressive onset of a breast lump.

GM is an uncommon breast lesion that is well known for its worrisome clinical presentations as a hard breast lump, particularly in younger women.

The etiology of GM is unclear. The postulate ,   include autoimmune disease, undetected organisms, reaction to childbirth and the use of oral contraceptives, but there are reports of GM occurring in patients who have not received oral contraceptives. Further, not all patients have a history of childbirth, and some have hyperprolactinemia.

The origin of GM is unknown, and its diagnosis rests on demonstrating a characteristic histological pattern, combined with the exclusion of other possible causes of granulomatous lesions in the breast and of breast cancer.

The most common clinical presentation is a firm unilateral, discrete breast mass, often associated with an inflammation of the overlying skin, usually present with progressive onset of a breast lump.

Affected women are nearly always parous and usually present in their early thirties. A tender extra-areola lump is the usual presentation associated with fixation to the skin or to the underlying pectoralis muscle. Occasionally, nipple retraction and lymphadenopathy is seen, and regional lymphadenopathy may be present in up to 15% of cases. The ladies will have a breast mass that can vary in size from 0.5 to 9 cm, and often the overlying skin is inflamed.

In more than 50% of reported cases, the initial diagnosis was considered malignant or suspicious for breast carcinoma.  Inflammatory breast lesions of this kind may be clinically mistaken for malignancy, particularly if reactive draining lymph nodes are enlarged. In 2 of these cases, patients presented with tender and enlarged nodes. Thus, a mammogram can be misleading when the symptoms demonstrate no abnormality but more often suggest carcinoma. As a result of the sinister nature of these signs, there is often a strong suspicion of breast cancer.

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 women with clinically suspicious breast lumps who are from high-risk populations and/or endemic areas.

  TB is an important differential diagnosis because of the implications of corticosteroid therapy; however, the histological features of GM differ from those of typical TB. TB and other infections need to be excluded by serological tests and histological study of the affected tissue with special stains and by examining cultures of the affected tissue for aerobic and anaerobic bacteria, mycobacteria and fungi.  Also, a woman in the reproductive age group who presents with a palpable lump in her breast might have TB; this must be considered, especially because the incidence of breast TB may increase with the global spread of AIDS.

Uncommon sites and similarities with other diseases clinically and radiographically occasionally lead to diagnostic and therapeutic delays.

FNAC may not always differentiate between GM and other diseases of the breast, and a confident diagnosis may require histological samples, negative microbiological investigations and clinical correlation.

Adequate tissue specimens are therefore needed to differentiate GM from other pathologies, including cancer and other causes of GM, such as TB, sarcoidosis and ductular ectasis. Combining the cytological features seen in the aspiration biopsy material with the histological appearance of the lesion led us to favour the diagnosis of GM.

The treatment of choice for GM is wide surgical resection of breast masses has been successful with corticosteroids have been reported to be useful. In cases of recurrence after biopsy or delayed wound healing, re-excision and a short therapy of high-dose steroids can be efficient. If there is no delayed wound healing or recurrence, no further therapy is required. Recurrence, fistula formation and secondary infection are well-known complications of GM, thus long-term follow-up is recommended. Neither wound complication nor recurrence has been identified as correct management of disease, corticosteroids used after healing postoperatively wound.

In conclusion, GM and breast TB are rare inflammatory diseases of the breast that can clinically mimic malignancy and which may be misdiagnosed as carcinoma. The diagnosis of GM must be based on a multidisciplinary approach. None of these cases were diagnosed clinically and radiologically before FNAC and biopsy, which emphasizes the awareness among surgeons, radiologists and pathologists of this unusual but distinctive disorder. Increased awareness of these diseases will improve understanding and management of them.

By Dr. Nina Vicol (General Endocrine Surgeon)

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