GRANULOMATOUS MASTITIS: AN AUTOIMMUNE PROCESS OR IDIOPATHIC? A CASE SERIES STUDY AMINA LODHI, PGY 3 MICHAEL GRISANTI, MD JOSEPH GRISANTI, MD BUFFALO RHEUMATOLOGY GRANULOMA • The term granuloma refers to a nodular organized aggregation of mononuclear inflammatory cells or collection of modified macrophages referred to as epithelioid cells, usually surrounded by a rim of lymphocytes and often containing multinucleated giant cells. Some granulomas may also contain eosinophils and plasma cells. ETIOLOGY OF GRANULOMATOUS INFLAMMATION INFECTIOUS CAUSES 1. BACTERIAL • TUBERCULOSIS • LEPROSY • CAT SCRATCH DISEASE 2. FUNGAL • HISTOPLASMOSIS • CRYPROCOCCOSIS 3. PROTOZOAL • SHISTOSOMIASIS AUTOIMMUNE CAUSES AUTOIMMUNE CAUSES 1.CROHN’S DISEASE 2.SARCOIDOSIS 3.VASCULITIS • GRANULOMATOSIS WITH POLYANGIITIS (WEGNER’S GRANULOMATOSIS) • GIANT CELL ARTERITIS • TAKAYASU’S ATERITIS • CHURG-STRAUSS SYNDROME INERT MATERIALS 1. SILICON 2. BERYLLIUM IDIOPATHIC PATHOGENESIS OF GRANULOMA FORMATION Events that give rise to the formation of granuloma and role of cytokines in the pathogenesis of granuloma (courtesy Robins Pathologic Basis of Disease, Chapter 5Diseases of the immune system) GRANULOMATOUS MASTITIS • Granulomatous mastitis also called granulomatous lobular mastitisis is a benign chronic inflammatory condition of breast which is diagnosed histologically by the presence of granulomas. • Its clinical presentation is very vague, mimicking breast abscesses, breast mass and inflammatory carcinoma of breast. • It has chronic course with frequent recurrences. GRANULOMATOUS MASTITIS ETIOLOGY: – Lactation – Trauma – Largely been considered idiopathic TREATMENT – SURGERY : As primary treatment modality. Wide local excision as well as radical mastectomy Outcomes of surgery_ recurrence, Failure to induce full remission, local scarring – MEDICAL TREATMENT: Prednisone and Methotrexate GRANULOMATOUS MASTITIS LITERATURE REVIEW – Most of the studies are either individual case reports or a series of case reports – Most of them come from Surgery, Dermatology, Radiology or Pathology – It has not been studied enough by the non- surgical subspecialties – The countries in which it is studied mostly include Italy, Turkey, India , Pakistan • Largest that has been done so far Granulomatous Lobular Mastitis: Imaging, Diagnosis andTreatment Linda J. Hovanessian Larsen, Banafsheh Peyvandi, Nancy Klipfel Edward Grant and Geeta Iyengar American Journal of Roentgenology2009193:2 574-581 Department of Radiology, University of Southern California Keck School of Medicine, USC/Norris Comprehensive Cancer Center, 1441 Eastlake Ave., Ste. 2315, Los Angeles, CA 90033 PATIENTS METHODS To investigate the association between granulomatous mastitis and autoimmunity we conducted a case series study of seven patients with histologically proven granulomatous mastitis who were being treated at Buffalo Rheumatology between 2010 and 2013. METHODS OBSERVED PARAMETERS: We measured different parameters in the patients history; age, race, history of rheumatic autoimmune disease and history of non-rheumatic autoimmune disease, personal or family history of breast cancer, history ofpregnacy and lactation and history of smoking. Then we focused on the clinical presentation of the disease and looked if the disease was unilateral or bilateral, the presence or absence of nipple discharge, other nipple changes, ulcers, palpable masses , draining sinuses, lymphadenopathy, presence or absence of constitutional symptoms, associated articular manifestations, extra-articular manifestations. METHODS OBSERVED PARAMETERS: •Also reviewed were the investigations to reach diagnosis including inflammatory and autoimmune markers, angiotensin converting enzyme levels as sarcoidosis is an important differential diagnosis to consider, ultrasound and mammographic description of the lesions and the histologic appearance of the lesions. Attention was also paid to the workup that was done to exclude infectious causes of granulomatous mastitis including gram stain, AFB stain, fungal and bacterial cultures. METHODS OBSERVED PARAMETERS: Finally we evaluated the treatment outcomes in these patients. We evaluated their response to 1. Immunosuppressive therapy which was measured as complete remission, near complete remission and partial remission 2. The role of antibiotics, 3. The surgical treatments RESULTS PARAMETERS OBSERVED IN HISTORY Mean age at presentation 42.83 years Race Caucasian Asian 5/7(71.42 %) 2/7(28.4%) History of Autoimmune disease 5/7 ((71.42 %). Rheumatic Autoimmune disease Non Rheumatic Autoimmune disease 3/5 (60%) 3/5 (42.8%) Sjogren’s Syndrome Rheumatoid Arthritis Vasculitis Hypothyrioidism Psoriasis without joint involvement 1 1 1 2 1 Personal history of breast cancer 1/7( 14.3%) Family history of Breast Cancer 1/7 (14.3%) History of Breast Implant 1/7 (14.3%) Smoking history 2/7 (28.6 %) Pregnancy within the last two years 2/7 (28.6 %) Breast feeding within the last two years 1/7 (14.3 %) STATISTICAL ANALYSIS OF THE AGE OF PATIENTS Mean 46.42857143 Median 42 Variance 206.6190476 Standard Deviation 14.37424946 PARAMETERS OBSERVED ON PHYSICAL EXAMINATION Constitutional symptoms Articular manifestations Fatigue (most common 83%), Fever, Night sweats, Weakness Arthralgia Arthritis 3/7 Chronic Neck and Back pain 1/7 (in association with 1/7 Rheumatoid arthritis) Extra-articular manifestations 3/7 Erythema Nodosum 1 laterality Dry mouth and dry eyes 1 Unilateral Psoriatic skin rash 1 Bilateral 5/7 (71.4%) Right Left 1/7 (14.3%) 1/7 (14.3 %) 4/7(57.1%) Nipple discharge 1/7 (14.3%) Draining sinuses 4/7 (57.1%) Abscesses and Ulcers 7/7 (100%) Lymph nodes palpable or detected on imaging Palpable as well as on imaging 1/7 (14.3%) On imaging alone 3/7 (42.8 %) Articular manifestations With Articular manifestations Without Articular manifestations 29% 71% Articular Manifestations:Detailed Analysis Arthritis arthralgia chronic neck and back pain Extra-articular manifestations:Detailed Analysis Erythema nodosum Dy mouth and dry eyes Psoriatic skin rash 20% 33% 20% 34% 60% 33% IMAGING STUDIES AND HISTOPATHOLOGY Ultrasound dilated ducts to complex cystic structures consistent with abscesses, dense parenchymal lobules, increased thickness of skin and subcutaneous nodules. Mammogram Mammographic changes reported were nodularity with internal echoes, hyper dense parenchymal changes, changes consistent with abscesses and enlarged lymph nodes. Histopathology All seven patients had histologically proven granulomatous mastitis. Other findings reported on histopathology included foreign body giant cells, acute mastitis, abscesses, and fat necrosis and duct ectasias. Most interesting association was with lymphocytic infiltration within in smooth muscles of walls of blood vessels of breast in one patient consistent with lymphocytic vasculitis of the breast Granulomatous inflammation with foreign body giant cells, ductal ectasia with eosinophillic cellular material, focal areas of fat necrosis Multiple vaguely nodular areas of neutrophils, mature lymphocytes, macrophages and plasma cells consistent with granulomas with necrosis, areas of fat necrosis Acute purulent mastitis with areas of fibrin-o-purulent material consisting of neutrophils and areas of granulomatous lobular mastitis Acute mastitis with abscess formation and granulomatous lobular mastitis with areas necrosis and multinucleated giant cells surrounding ducts. Diffuse fibrin-o-purulent material. Abscess formation with areas of granulomatous inflammation with foreign body giant cells and granulation tissue, Areas of fat necrosis. Areas of fat necrosis, blood vessels with lymphocytes within the smooth muscle walls-lymphocytic vasculitis of breast with areas of granulomatous inflammation INFECTIOUS DISEASE WORKUP AND ANGIOTENSIN CONVERTING ENZYME Gram stain Negative AFB Negative Bacterial Cultures Negative Fungal Cultures Negative Angiotensin Converting Enzyme Negative MARKERS OF AUTOIMMUNITY Patient 1 Negative Patient 2 ANA 1:132, speckled pattern Patient 3 Elevated ESR,CRP, Positive Anti SSB, reduced C3 Patient 4 Negative Patient 5 Elevated ESR, IgE level very high Patient 6 Anti CCP Positive Patient 7 ANA positive, pANCA Positive TREATMENTS AND OUTCOMES OF TREATMENT Patient 1 2 3 4 5 6 7 Incision and Drainage Yes Yes Yes Yes Yes yes yes Excision No No No No Yes, local excision no no Antibiotics Multiple Courses Multiple Course Multiple Courses Multiple Courses Multiple Courses Multiple Courses Multiple Courses Prednisone Yes Yes Yes Yes Yes Yes Yes Methotrexat e yes Yes Yes Yes Yes Yes Yes Treatment outcomes Full Remission Full remission Full Remission Full Remission Partial remission Near Complete remission Near complete remission Negative history Granulomatous mastitis No Autoimmune Markers No Autoimmune Markers ? Granulomatous mastitis History of hypothyroidism Negative history No Autoimmune markers Negative History No Autoimmune Markers History of bilateral breast implants, Psoriasis History of Rheumatoid Arthritis Ani CCP Positive ANA Positive 1:320,speckled ? Granulomatous mastitis, Sjogren syndrome, ESR, CRP, Positive Anti SSA ? Granulomatous mastitis ? Granulomatous mastitis Elevated ESR, Elevated IgE levels Granulomatous mastitis History of Hashimoto thyroiditis, Granulomatous mastitis in breast cancer,Treated with association with Lymphocytic vasculitis of breast,Positive lumpectomy/radiation and ANA pANCA chemotherapy ? ? ? markers of autoimmunity in 71% of patients and that • CONCLUSION __ ________ __ _______ __ __________ ________ ___ ___ _______ __ immunomodulation with prednisone and methotrexate was able to induce remission shows ___ that____ it there is role of autoimmunity ____________ __ __ ________ ________________ ____ __________ ___ ____________ ___ ____ __ ______ _________ _____ ____ __ _____ __ ____ in it. __ ____________ __ __ •• 29________ % patients had no autoimmune markers__positive, history ___ __ __________ _______ ________ _______ __no ___ __________ ________ _____ _______ _____ ______ __ _____________ __ ___ of any autoimmune disorder which demands close follow up __ ____ _______ _____ ___ ________ __ ___ __________ ________ __ prospectively to________ see if they develop signs__ and symptoms of any ___________ ____ __________ _______ ________ __________ _______ autoimmune • disorder or seroconvert from negative _ ___ __ _ _______ ________ __ _ _________ ________ __ ___________ ____ autoimmune markers to positive autoimmune markers . _____ __________ ________ • It can be a primary disorder or a secondary disorder in CONCLUSION • Granulomatous mastitis is a medically manageable disease with the mainstay of treatment being immunosupressive therapy • Failure to induce remission and recurrence is not uncommon with primary immunomodulating agents • Considering important role of TNF in the pathogenesis of formation as well as maintenance of granuloma, there can be a potential role of anti TNF therapy in such patients who fail to respond to first line immunosuppressive agents. • Role of surgery is only limited to the incision and drainage in case of signs and symptoms of concurrent infection, biopsy and excision for the purpose of diagnosis CONCLUSION More studies are needed to be done, retrospectively as well as prospectively 1. To find the association between granulomatous mastitis and autoimmune disorders and different autoimmune markers. 2. To find if there are any markers which are unknown to us at this time which are either specifically associated with granulomatous mastitis or are common between granulomatous mastitis and other autoimmune disorders 3. To identify the environmental, clinical as well as biological factors that play a role in the pathogenesis of granulomatous mastitis 4. To formulate reasonable treatment algoriths to treat it with success CONCLUSION • There is a need to spread awareness of this disease among the PCP as well as specialists , so that these patients who present with recurrent breast abscesses with failure to respond to antibiotics and multiple incision and drainage with little or no success can be identified , worked up for this diagnosis and managed appropriately.