Granulomatous Mastitis (GM) and Idiopathic Granulomatous Mastitis (IGM)

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Methodology

Strong Consensus	If >90% of panelist rate a recommendation as either “strongly agree” or “agree” and the median score is 1
Consensus	If > 75% and <90% of panelists rate a recommendation as either “strongly agree” or “agree” and the median is either 2 or 1
No Consensus	any other rating scores

1. Initial Management

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* 1a. In patients in which GM is suspected, an aspiration and core needle biopsy of the abscess cavity wall should be performed. Fluid should be sent for anaerobic, aerobic bacteria, acid fast bacilli for Tuberculosis, Corynebacterium, fungus and mycobacteria testing. Tissue should be sent to histopathology to rule out cancer and for pathologic evaluation. (Strong Consensus)

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* 1b. Clinicians should empirically treat GM with doxycycline or Bactrim while awaiting final culture results. (Strong Consensus)

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* 1c. Clinicians should institute short term symptom management as soon as possible for patients with suspected GM. Symptom management strategies include topical non-adherent gauze pads over any open wounds, warm compresses to assist with spontaneous drainage of abscess fluid collections and ice for inflammation and pain relief. (Strong Consensus)

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* 1d. Patients with clinical symptoms of GM in the setting of negative (sterile) cultures and the following histologies (see below) on core biopsy should be treated as IGM. (Strong Consensus)

Histologies can include: non-caseating granulomas, multinucleated giant cells, plasma cells, polymorphonuclear cells, leukocytes, lymphocytes, sterile microabscesses, cystic neutrophilic mastitis

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* 1e. Clinicians should consider prescribing a short course of anti-inflammatory medications (i.e. Celecoxib) for inflammation and/or symptom control in patients with IGM. (Strong Consensus)

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* 1f. Clinicians should counsel patients with IGM that the disease process is self-limiting and can take 5-18 months to resolve despite treatment and symptom management. Patients should be informed that IGM does have a high recurrence rate. (Strong Consensus)

2.Percutaneous Interventions

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* 2a. Abscess drainage/aspiration can be performed for patients with IGM to obtain culture material and/or for symptom relief. However, routine aspiration alone is not recommended, as these sterile abscesses will drain and resolve spontaneously over time. (Strong Consensus)

3. Imaging

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* 3a. Patients at initial presentation of GM should undergo a mammogram and ultrasound to help with treatment planning and to rule out malignancy. (Strong Consensus)

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* 3b. Follow-up imaging during treatment for IGM should be considered if there is symptom progression. (Strong Consensus)

4. Indications for Surgery

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* 4a. Clinicians should be aware that incision and drainage procedures for IGM are rarely indicated because many of these lesions will spontaneously drain and heal without any intervention. (Strong Consensus)

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* 4b. Surgical excision for idiopathic IGM is not recommended and should be considered only as a last resort if the complete area can be excised. (Strong Consensus)

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* 4c. Mastectomy should only be considered if the mastitis has been refractory to all other treatment modalities. Multidisciplinary input and patient preference should inform a decision for mastectomy for patients with IGM. (Strong Consensus)

5. Performance of the Surgical Procedure

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* Not applicable

6. Other non-Surgical Management

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* 6a. Clinicians should consider non-operative management for IGM prior to any surgical intervention. (Strong Consensus)

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* 6b. Clinicians may consider topical prednisolone steroids for fistulous tracts for symptom relief for patients with IGM. (Strong Consensus)

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* 6c. For patients with IGM with worsening symptoms such as increased abscesses, increase in size, drainage or pain, injection of Triamcinolone steroid into the abscess cavity wall can be considered. (Strong Consensus)

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* 6d. Clinicians can administer oral steroid taper regimens for patients with IGM who have multiple abscesses, a large extent of disease or cases refractory to abscess steroid injections. (Strong Consensus)

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* 6e. Biologic medications, such as Methotrexate or Azathioprine, can be considered for patients with IGM who are refractory to oral steroids, preferably in consultation with rheumatology. (Strong Consensus)

7. Follow Up Care

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* 7a. Clinicians should consider follow up of IGM cases every 6-12 months after initial presentation because of its refractory nature. (Strong Consensus)

Appendix 2. Literature Search Results

A review of the literature was conducted in support of development of these pathway recommendations. Search parameters and resulting references are below.  

Search Parameters:  
Idiopathic granulomatous mastitis 
Filters applied: Clinical Trial, Controlled Clinical Trial, Meta-Analysis, Randomized Controlled Trial, Systematic Review, in the last 10 years, Humans, English. 

1. Martinez-Ramos D(1), Simon-Monterde L(1), Suelves-Piqueres C(1), Queralt-Martin R(1), Granel-Villach L(1), Laguna-Sastre JM(1), Nicolau MJ(1), Escrig-Sos J(1). Idiopathic granulomatous mastitis: A systematic review of 3060 patients. Breast J. 2019 Nov;25(6):1245-1250. doi: 10.1111/tbj.13446. Epub 2019 Jul 4. 

2. Lei X(1)(2), Chen K(1)(2), Zhu L(1)(2), Song E(1)(2), Su F(1)(2), Li S(1)(2). Treatments for Idiopathic Granulomatous Mastitis: Systematic Review and Meta-Analysis. Breastfeed Med. 2017 Sep;12(7):415-421. doi: 10.1089/bfm.2017.0030. Epub 2017 Jul 21. 

3. Godazandeh G(1), Shojaee L(2), Alizadeh-Navaei R(3), Hessami A(4)(5)(6). Corticosteroids in idiopathic granulomatous mastitis: a systematic review and meta-analysis. Surg Today. 2021 Dec;51(12):1897-1905. doi: 10.1007/s00595-021-02234-4. Epub 2021 Feb 15. 

4. Pandey TS(1), 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 May-Jun;20(3):258-66. doi: 10.1111/tbj.12263. Epub 2014 Mar 27. 

5. Yildirim E, Kayadibi Y, Bektas S, Ucar N, Oymak A, Er AM, Senturk A, Demir IA. Comparison of the efficiency of systemic therapy and intralesional steroid administration in the treatment of idiopathic granulomatous Mastitis. The novel treatment for Granulomatous Mastitis. Ann Ital Chir. 2021;92:234-241. 

6. Montazer M(1), Dadashzadeh M(1), Moosavi Toomatari SE(1). Comparison of the Outcome of Low Dose and High-Dose Corticosteroid in the Treatment of Idiopathic Granulomatous Mastitis. Asian Pac J Cancer Prev. 2020 Apr 1;21(4):993-996. doi: 10.31557/APJCP.2020.21.4.993. 

7. Gunduz Y(1), Altintoprak F, Tatli Ayhan L, Kivilcim T, Celebi F. Effect of topical steroid treatment on idiopathic granulomatous mastitis: clinical and radiologic evaluation. Breast J. 2014 Nov-Dec;20(6):586-91. doi: 10.1111/tbj.12335. Epub 2014 Sep 17. 

8. Çetin K(1), Sıkar HE(2), Göret NE(2), Rona G(3), Barışık NÖ(4), Küçük HF(2), Gulluoglu BM(5)(6). Comparison of Topical, Systemic, and Combined Therapy with Steroids on Idiopathic Granulomatous Mastitis: A Prospective Randomized Study. World J Surg. 2019 Nov;43(11):2865-2873. doi: 10.1007/s00268-019-05084-x. 

9. Chen K(1), Zhu L(2), Hu T(2), Tan C(3), Zhang J(4), Zeng M(2), Li S(5), Song E(6). Ductal Lavage for Patients With Nonlactational Mastitis: A Single-Arm, Proof-of-Concept Trial.J Surg Res. 2019 Mar;235:440-446. doi: 10.1016/j.jss.2018.10.023. Epub 2018 Nov 19. 

10.  Agochukwu NB(1), Wong L. Diabetic Mastopathy: A Systematic Review of Surgical Management of a Rare Breast Disease. Ann Plast Surg. 2017 Apr;78(4):471-475. doi: 10.1097/SAP.0000000000000879. 

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