B. Caballero2, J. Sugandi1,2, R. K. Viscusi1,2 1Banner- University of Arizona,Department Of Surgery,Tucson, AZ, USA 2University Of Arizona,College Of Medicine,Tucson, AZ, USA
Introduction: Granulomatous mastitis (GM) is a rare, benign, chronic inflammatory disease of the breast that usually affects women of child bearing age. The most common clinical symptoms are a palpable breast mass associated with overlying erythema, induration, pain or drainage. Imaging is non-specific and histopathology is needed for confirmative diagnosis. The etiology is unclear, but an autoimmune reaction is favored and it has been linked to prior contraceptive use, a history of pregnancy and breastfeeding. Given the limited knowledge of etiology, initial treatment of this benign, yet locally aggressive disease remains controversial. Observation alone, antibiotics, surgical excision, steroids alone, and immunosuppressive agents have all been described in the literature. There is no consensus on treatment but knowing GM is generally a self-limited disease and surgery can be associated with poor cosmetic outcomes, a non-invasive alternative such as methotrexate (MTX) is a viable option.
Methods: A retrospective chart review of patients with histologically confirmed GM between January 2013 and December 2017 was analyzed to identify response to MTX treatment. Eight adult female patients, age range 29-57, were diagnosed with GM via excisional or core breast biopsy. Methotrexate treatment was planned for all 8 patients with confirmed GM. Liver function tests and a full blood count were evaluated during treatment course. Treatment protocol included MTX administered at 2.5-10 mg orally together with folic acid in one dose, once a week.
Results: On physical exam, a palpable breast mass was detected on 8 patients. All patients underwent ultrasound examination and after diagnosis of GM was confirmed, MTX + folic acid treatment was initiated. Treatment was administered for 3-15 months. One patient discontinued MTX due to plans to conceive. None of the patients developed complications from MTX and no recurrence was observed during follow up periods. Patients noted relief of symptoms including, erythema, breast tenderness and nipple discharge following 30-60 days of MTX treatment.
Conclusion: Evidence in most literature has shown most patients with GM have a troublesome course of recurrence. There is no consensus on treatment but non-invasive alternatives such as steroids and methotrexate are good options. More cases using methotrexate alone or in combination with corticosteroids are needed to confirm those results. Ultimately, treatment depends on the size of the lesions and symptom severity. Prompt diagnosis and treatment with methotrexate can often treat the disease or provide symptomatic improvement without subjecting patients to multiple trials of medications that could pose risks of adverse effects.