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ORIGINAL ARTICLE Bilateral idiopathic granulomatous Mehmet Velidedeoglu a, Fahrettin Kilic b, Birgul Mete c, Mucahit Yemisen c, Varol Celik a, Ertugrul Gazioglu a, Mehmet Ferahman a, Resat Ozaras c, Mehmet Halit Yilmaz b, Fatih Aydogan a,*

a Department of General Surgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey b Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey c Department of Infectious Diseases, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey

Received 1 July 2014; received in revised form 24 February 2015; accepted 25 February 2015 Available online 2 May 2015

KEYWORDS Summary Objectives: Idiopathic (IGM) is a benign rare inflammatory cancer; pseudotumor. Bilateral involvement of IGM has been reported in a few cases. To our knowl- cancer; edge, this study is the largest series of bilateral cases to date. The goals of this study were corticosteroids; to present clinical features of bilateral IGM and to evaluate the results of treatments. granulomatous Materials and methods: We performed a retrospective review of the idiopathic granulomatous mastitis; mastitis database from 2010 to 2013. Ten female patients who met required histologic and clin- idiopathic; ical criteria of IGM in both were included in study. Demographic data, clinical findings, tuberculosis medication history, and radiologic findings are presented. Results: The mean age at onset of the disease was 38.4 8.3 years (range: 29e52 years). Nine patients had no recurrence during a mean follow-up period of 21 months (range: 11e26 months). Additionally, the median time to second breast involvement was 15.6 months. Conclusion: Bilateral IGMs have a higher rate of more relapse and greater resistance to medical therapies than do unilateral IGMs. Surgical management should be avoided unless all medical treatment options have been exhausted. Nevertheless, expectant management seems a rational option for the treatment of bilateral IGM. Copyright ª 2015, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved.

Conflicts of interest: Authors of the manuscript declare no conflict of interest. They certify that all their affiliations with or financial involvement in, within the past 5 years and foreseeable future, any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript are completely disclosed (e.g., employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, royalties). _ _ * Corresponding author. Istanbul U¨niversitesi Cerrahpas‚a Tıp Faku¨ltesi Yerles‚kesi, Genel Cerrahi AD 34098 Fatih/Istanbul, Turkey. E-mail address: [email protected] (F. Aydogan).

http://dx.doi.org/10.1016/j.asjsur.2015.02.003 1015-9584/Copyright ª 2015, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved. Bilateral idiopathic granulomatous mastitis 13

1. Introduction the shortest and longest intervals after childbirth were 1 year and 10 years, respectively. None of the patients were Idiopathic granulomatous mastitis (IGM), also known as breast-feeding. None of the patients had a history of idiopathic granulomatous lobulitis, is an uncommon, benign tuberculosis or systemic granulomatosis, but three had a inflammatory pseudotumor that was first reported by family history of tuberculosis. Kessler and Wolloch in 19721. Clinically, IGM presents as a The most common presenting symptom was a hard mass, Z palpable hard lump with erythematous skin changes or which was detected in all of the patients (n 10; 100%). lymph node involvement, which may lead to Additionally, seven presented with redness of the skin discharge or retraction, sinus formation, breast , (70%), and draining sinuses (fistulas) or discharge from the e Z and “apple jelly” scars2 8. IGM is usually unilateral and can breast skin (n 7; 70%). Nine patients had no recurrence e be seen in all quadrant regions, except for the subareolar during a mean follow-up period of 21 months (range: 11 26 area9,10. months). Only one patient had static disease, at a follow-up Few cases of bilateral involvement have been reported duration of 26 months (Fig. 1). in the literature11e13. To our knowledge, this study, which includes 10 bilateral IGM cases, is the largest series of 3.2. Radiologic findings bilateral cases to date. The goals of this study were to present the clinical features of bilateral IGM and to eval- The most useful method for evaluating the radiologic uate the results of treatment. appearance of IGM is sonography. The technique defines valuable data for infectious conditions such as effusions, 2. Materials and methods inflammation of parenchyma and fatty tissues, abscess formations, fistula tracts. These are the key findings for discriminating the suspected lesions from malignancy. In- Between 2010 and 2013, 10 female patients who met the formation of the patients’ history is essential to assess required histologic criteria of IGM in both breasts were before evaluation. Sonography examination showed a included in this retrospective study. The patients were hypoechoic collection in nine patients (90%), solid lesion in referred to our mastitis study group from the Outpatient one patient (10%), thickening of the breast skin in eight Departments of the General Surgery and Infectious Diseases patients (80%), fistula tracts in four patients (40%), and Clinics. Our study group included three infectious disease ductal fillings and postobstructive dilatation in three pa- physicians, two radiologists, two pathologists, and two tients (30%). Mammographic findings were nonspecific in breast surgeons. The diagnosis was confirmed by core bi- the three patients who underwent mammograms. Magnetic opsy of the suspicious breast lesions and biopsy specimens resonance imaging (MRI) evaluation may demonstrate the taken from the abscess wall. The pathological criteria for extension of the disease and may be used to clarify the the diagnosis of IGM were the presence of the characteristic suspected diagnosis. MRI was performed for three cases; histopathological features of a noncaseating granulomatous asymmetrical enhancement with nonspecific contrast inflammation centered on breast lobules, in the absence of enhancement kinetics and fluid collections were common. any evidence of specific underlying causes. The presence of epithelioid histiocytes, lymphocytes, plasma cells, poly- morphonuclear leukocytes, and multinucleated Langhans- 3.3. Medication history type giant cells without caseous necrosis were demon- strated in each case. Treatment outcomes were evaluated All patients (100%) had previously taken antibiotics, six by physical examination and ultrasonography (US). The patients (60%) had undergone drainage before presenting clinical data in terms of the presentation, histopathology, at our clinic and four patients (40%) (Cases 1, 7, 8, and management, recurrence, discharge from the clinic, and 10) were treated with a second course of antibiotics follow-up at monthly intervals were analyzed by a review of (Table 1). the medical records. The Ethics Committee of Istanbul We sent all the biopsy samples to the histopathology University Cerrahpasa Medical School, Istanbul, Turkey department. The characteristic caseating granulomas for approved the study. The document number is 83045809/ TB was observed only in one and this sample was sent for TB 604/02-15545/Date: June 5, 2014. culture as well. All were stained with Periodic Acid Schiff (PAS) and Ehrlich Ziehl Neelsen (EZN) to demonstrate the 3. Results microorganisms within the tissue; all remained negative. Case 1 had two recurrences and received antibiotics and meloxicam. The patient was offered steroid treat- 3.1. Demographic data and clinical findings ment but refused. Following cessation of medications, the patient had expectant conservative management followed Table 1 provides the clinical characteristics of the patients. by complete spontaneous recovery. Cases 8 and 10 showed The mean age at onset of the disease was 38.4 8.3 years complete disease resolution and no recurrence with (range: 29e52 years). The patients had no history of breast expectant management. Case 7 had a history of antitu- carcinoma and no family history of granulomatous mastitis. berculous therapy and a complete recovery of IGM in her All but two patients were of reproductive age, and all were left breast, and she was referred to us for a lump affecting parous. The parity of the patients ranged from two to five, the right breast. No previous pathological or microbio- with a mean parity of three. None of the patients had a logical data regarding tuberculosis were available. Core recent history of pregnancy at the time of the presentation; needle biopsy was performed, and the specimen was 14 M. Velidedeoglu et al.

Table 1 Clinical characteristics of patients with bilateral IGM. Patient’s characteristics Case 1 Case 2 Case 3 Case 4 Age (y) 52 51 30 33 Parity 3 4 4 2 Past lactation Yes Yes Yes Yes Oral contraceptive use No No No No Tobacco smoking Yes No Yes Yes Trauma history to the breast No No No No Medical history DM Hashimoto’s thyroiditis No No Family history in relation No No Yes No to TB First admission to us No No No No Presentation time 8 y after 6 y after 5 y after 2.5 y after childbirth childbirth childbirth childbirth Total duration of breast- 36 17 60 7 feeding (mo) Initial complaint A hard mass A hard mass and redness A hard mass and A hard mass and of the skin redness of the skin redness of the skin Time from onset of symptoms 6241412 to diagnosis (mo) First affected breast side Right Right Left Right Duration for the second 612123 breast involvement (mo) Size and location of mass in 2 cm, Upper inner 2.5 cm, Upper inner 3 cm, lower inner 4 cm, Upper inner right breast quadrant quadrant quadrant quadrant Size and location of mass in 2.5 cm, Upper inner 2 cm, Upper outer 3 cm upper quadrant 4 cm, Upper outer left breast quadrant quadrant close to aerola quadrant Core needle biopsy Yes Yes Yes Yes Tuberculin skin test (mm) 20 Anergic 28 9 Acid fast stain Negative Negative Negative Negative Rose Bengal Negative Negative Negative Negative Radiologic tool US US US US Abscess drainage Yes Yes Yes Yes Antibiotics Amoxicillin-clavulanate Amoxicillin-clavulanate Ceftidoren pivoxil Ceftriaxon þ ornidazol Steroid therapy No Previously Yes Yes Antituberculous therapy No Yes No No Recurrence Yes Yes Yes Yes Outcome Healed Healed Healed Healed Unsightly scars Yes, bilateral Yes, bilateral Yes, bilateral Yes, bilateral DM Z diabetes mellitus; IGM Z idiopathic granulomatous mastitis; US Z ultrasonography.a The data are not available due to histopathological sampling of outer clinic. confirmed to be granulomatous mastitis; bacterial culture complete recovery following cessation of steroid therapy. was negative. This patient was managed conservatively Nonetheless, the recurrent disease responded well to a with regular clinical and radiological surveillance. After 2 second course of oral prednisolone and the dose was months of follow-up, the patient showed complete re- tapered slowly. However, after a short time period, she covery. One month later, she received meloxicam 15 mg again developed recurrence. Expectant conservative once per day for 1 month to treat her pain. Until 2013, management was preferred, and the patient experienced none of these four patients recurred without medication. complete spontaneous recovery after 5 months. Interest- Four (40%) patients (Cases 3, 4, 6, and 9) were treated ingly, this patient became pregnant during this recovery with oral prednisolone for 6 weeks at an initial dose of period. Case 9 showed complete recovery after a course 0.5 mg/kg/d in divided doses (4 þ 2), which were tapered of steroid therapy. Case 6 developed recurrence following slowly with clinical improvement. Of these, Case 3 cessation of steroid therapy, but the patient showed developed recurrence when the prednisolone dose was complete recovery after a second course. Case 2 had no tapered. As the dose was increased, the patient seemed clinical response to steroid treatment; however, the pa- to respond, but the medication was stopped because she tient showed complete remission after undergoing com- became pregnant. She underwent expectant conservative bined antituberculous therapy (rifampicin, ethambutol, management, and experienced complete spontaneous and isoniazid) for 6 months. Case 5 had no response to recovery. Case 4 developed recurrence 2 months after a antituberculosis treatment, so she received oral Bilateral idiopathic granulomatous mastitis 15

Case 5 Case 6 Case 7 Case 8 Case 9 Case 10 34 40 43 32 29 40 2452 33 Yes Yes Yes Yes Yes Yes No No For 45 d 15 y ago No No No Yes Yes No Yes No No No No No No No No No No No No No No Yes No Yes No No No

No No No No No No 5 y after childbirth 1 y after childbirth Over 2 y after 10 y after childbirth 4 y after childbirth 6 y after childbirth childbirth Over 12 mos 48 120 12 27 60

A hard mass and A painful hard A hard mass and A painful hard mass A hard mass and A hard mass and redness of the skin mass redness of the skin redness of the skin redness of the skin 15 14 30 12 4 9

Left Left Left Right Left Left 15 8 48 24 4 24

6 mm, Upper outer 1 cm, Upper outer 4 cm, Upper outer 3 cm, Upper inner 1 cm, Upper outer quadrant quadrant quadrant quadrant quadrant 3 cm, Upper inner 2 cm, Upper outer No data (left lesion 3 cm, Upper inner 3 cm, Upper outer No data(left lesion quadrant quadrant 4 y ago) quadrant quadrant 2.5 y ago) Yes Yes Yes Yes Yes Yes 17 8 20 8 9 Not performed Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative US US US US US US Yes Yes No Yes Yes Yes Amoxicillin- Amoxicillin- Fusidic acid Amoxicillin- Amoxicillin- Ciprofloxacin þ clavulanate clavulanate clavulanate clavulanate Metronidazole Yes, later Yes No No Yes No Yes, initial No Previously No No No Yes Yes Yes Yes Yes Yes Resistant Healed Healed Healed Healed Healed Yes, in left breast Yes, in left breast Yes, in right breast Yes, in right breast Yes, in left breast Yes, in left breast prednisolone. She recurred twice following cessation of has been documented, underdiagnosis of tuberculosis steroid therapy because of intolerance, but showed a mastitis might be a major reason for the increased complete response thereafter. After 2 years, she experi- prevalence19,20. enced a second recurrence, which is at present being The diagnosis and treatment of IGM remains challenging. treated with antibiotic therapy. There was a notable delay IGM can mimic breast abscess or inflammatory breast can- between onset of symptoms and diagnosis, a median of 14 cer in terms of physical and radiological findings. It typi- months in our study. Additionally, the median time to cally presents as a unilateral palpable firm , second breast involvement was 15.6 months (Figs. 2e4). with occasional , peau d’orange change, erythema, nipple inversion, breast asymmetry, draining si- nuses, and scars, which are manifestations of intrinsic in- 4. Discussion flammatory or neoplastic breast disease1,2,8,16,21. Abscess and fistula formation, ulceration, deformity of the breast, IGM is a rare, nonmalignant, chronic inflammatory breast and unsightly scars are common complications of IGM. condition of unknown etiology that has received little Although this disease is not life-threatening such as other attention in the literature11. Almost 200 cases have been malignancies, it seriously depresses the social life of the reported during the past three decades, with most patient3,16,17,21e24. cases occurring in females from Mediterranean countries All of our patients had hard masses as the initial (Turkey and Jordan) and Asia (China, Arabia, and complaint, which were painful in only two patients. Six Malaysia)2,3,5,11,14e18. Although no ethnic predisposition (60%) patients had redness of the skin. There was a 16 M. Velidedeoglu et al.

Figure 1 The picture presents the deformation of the breast due to skin fistulas of IGM. IGM Z idiopathic granulomatous mastitis. tendency for local recurrence and delayed wound healing. All of our patients had at least one recurrence, and most experienced inadequate or no response to various treat- ment modalities. IGM is seen mostly in females of childbearing age with a history of pregnancy and lactation in the previous 5e6 years9,11,25. Although the youngest and oldest females ever reported were aged 11 years and 83 years, respectively, the disease usually appears in the breast in the third or fourth decade3,17,19. However, younger patients were reported in recent trials2,26e30. In our study, the mean age of patients at onset of the disease was 38.4 years. There was a notable delay between onset of symptoms and diagnosis, a median of 14 months in our study. As IGM is rare, this disease is not routinely considered as a differ- ential diagnosis of a simple breast abscess. Surgical drainage or US-guided aspiration is commonly preferred in practice in place of core-needle biopsy or incisional biopsy from the abscess wall, which may explain the prolonged time to diagnosis. The median time to second breast involvement was 15.6 months. No response to antibiotics was observed in three of the 10 unilateral mastitis cases before the second breast was involved. Two patients showed no response to antibiotics and steroid therapy before bilateral involvement. One patient showed a partial response to antibiotics, but bilateral involvement occurred thereafter. Three patients showed a complete response (1 Figure 2 Common sonographic findings of IGM (AeC). (A) The responded to antibiotics, 1 to antibiotics and steroids, and most common finding is hypoechoic collections without well 1 to antibiotics and abscess drainage), but they later defined contours; (B) skin thickening secondary to inflamma- developed bilateral involvement. Only one patient showed tion should be compared with contralateral breast; right breast complete disease resolution after antituberculosis treat- skin was thickened compared with the left breast; and (C) ment; unfortunately, the other breast showed involvement hypoechoic fistula tracts is specific finding and should be fol- 48 months later. We concluded that bilateral IGMs were lowed due to fistula formation. IGM Z idiopathic granuloma- resistant to medical treatment, and tended to relapse and tous mastitis. recur. All of our patients had a history of pregnancy, were parous, and had breast-fed. No patient experienced et al35 found no association with lactation. In Cases 3 and 4 symptom-onset during lactation. These results are in in our series, the medication was stopped because the accordance with previous reports that pregnancy and patients became pregnant. These patients had expectant breastfeeding conditions are associated with an increased conservative management, and experienced complete risk of IGM15,26,31e34. However, Azlina et al18 and Fletcher spontaneous recovery. It is unclear whether being pregnant Bilateral idiopathic granulomatous mastitis 17

Figure 4 The picture presents the bilateral synchronous involvement in a 34-year-old woman.

contraceptive hormones. Only one of our patients used oral contraceptives for a short period 15 years ago. The patients in the study by Azlina et al18 were nonsmokers. In addition, the patients had no history of local trauma to the breast in the Ozel et al30 study. In our study, six patients were smokers, but none reported a history of local trauma. An association between periductal mastitis (but not IGM) and nicotine addiction has been established, as seen in more than half of our patients (60%); moreover, smoking may delay recovery and extend IGM disease involvement to the second breast. Although unilateral IGM is typical in previous reports, bilateral involvement has been included in only a maximum of two patients in these studies4,12,30. Bilateral involvement has been reported at a lower frequency, and we found no reports of a bilateral IGM series. Some authors reported more common involvement of the right breast16,19,35, whereas others reported left or equal involvement30,39.In our study, the left breast was the first affected in six of 10 Figure 3 (A,B) MRI images of bilateral IGM. (A) Contrast nd patients. enhanced T1 weighted reformat substraction (2 minute) For an accurate diagnosis, IGM must be differentiated image shows wide asymmetrical nonmass enhancement in right from other disorders such as tuberculosis, sarcoidosis, breast and retroareolar disease in left. (B) Corresponding color foreign body reaction, ductal ectasia, mycotic infection, overlay T1 weighted axial scan provided by the computer-aided Wegener’s granuloma, and histoplasmosis40. Diagnostic diagnosis (CAD) system represents nonspecific contrast tests for tuberculosis include the purified protein derivative Z enhancement kinetics in both breasts. IGM idiopathic (PPD) skin test, in vitro interferon-gamma assay and poly- Z granulomatous mastitis; MRI magnetic resonance imaging. merase chain reaction. Ziehl-Neelsen (ZN) stain PPD and routine histology studies are sometimes insufficient to or receiving expectant management therapy contributed to exclude tuberculosis mastitis16,41,42. In our study, periodic their recovery. Kaur et al36 reported that prolonged breast- acid-Schiff (PAS) and ZN acid-fast stains failed to identify feeding might cause long-term distension of acini and specific causative organisms in any of the 10 patients. The ducts, causing them to rupture. They suggested that this PPD skin test was not performed in one patient. Four pa- factor might cause a granulomatous response. Baslaim tients had positive PPD skin test results (> 10 mm in- et al2 opposed this idea; they reported that patients, durations). Case 2 was anergic for PPD, and she did not especially nursing mothers who had breast-fed from one respond to steroid treatment; therefore, she commenced breast only, developed the disease in the contralateral combined antituberculous therapy (rifampicin, etham- breast. butol, and isoniazid) for 6 months and showed complete The etiology of IGM is unclear; however, many factors, remission. Further differential diagnoses were negative, such as local irritants, oral contraceptives, nicotine addic- including a chest X-ray, the Rose Bengal test, and the tion, and breast trauma, have been consid- antidsDNA test. ered2,3,9,15,16,30,37,38. No patients included in the studies by US, mammography, and MRI have limited roles in dis- Ozel et al30, Azlina et al18, or Neel et al39 used oral tinguishing granulomatous mastitis from malignancy. 18 M. Velidedeoglu et al.

Mammographic examination may show a focal asymmetrical therapy or tapering off the dose57,60. One of our patients density in dense breast parenchyma or a mass with a relapsed when the steroid dose was tapered-off. Two pa- recognizable margin in fatty breasts. US has been used to tients developed recurrence after a complete recovery describe the disease as inhomogeneous hypoechogenicity following cessation of steroid therapy. Only one of four with internal hypoechoic tubular lesions4,10,19,25,43e45.Itis patients who was given prednisone showed complete re- possible to discriminate benign neoplastic lesions from covery after a course of steroid therapy, and no relapse cancer using dynamic contrast-enhanced MRI; however, this occurred. However, no relationship was detected between method has lower specificity for distinguishing granuloma- the second breast involvement and the withdrawal of the tous mastitis from . Therefore, MRI may sup- steroid therapy or tapering off the dose in our patients. port US and mammography findings in distinguishing benign As steroids exacerbate infectious disease, all suspicious inflammatory lesions from malignant lesions5,45e47. MRI aids infectious etiology should be excluded before commencing the surgical approach by delineating the extent of the steroids33,64. If there is a likelihood of a superinfection disease, as edema of the breast skin and tissue prevent because of the presence of inflammatory signs, antibiotics precise evaluation by US12. In our study, US revealed locu- as an initial treatment may be offered until a definitive lated fluid collections of various sizes and ill-defined diagnosis is reached, otherwise antibiotics have no thera- hypoechoic masses in three cases. Two patients under- peutic value for true cases of IGM62. Our policy is to went breast MRI previously in other centers. In one case, perform surgical drainage and offer antibiotics prior to ductal carcinoma in situ was suspected based on MRI; starting systemic corticosteroids if the disease is compli- however, US-guided biopsy proved the diagnosis to be IGM. cated by abscess. Even though it was rarely investigated, Consequently, there are no IGM-specific radiological find- immunosuppressive therapy including MTX and azathioprine ings. US and mammography are used to rule out breast has been considered an alternative option in cases of cancer in centers that have experienced numerous cases of recurrence, resistance, and side effects of predni- IGM. Diagnosis is confirmed on tissue sampling biopsy by sone26,53,57,65. We did not prefer this medication for our revealing noncaseating granuloma with epithelioid histio- patients. cytes, giant cells, plasma cells, and eosinophils confined Complicated and resistant cases might benefit from within breast lobules48. steroids after excision19. Gurleyik et al58 recommended No clear consensus exists in the literature regarding the consecutive surgical excision of the remaining tissue after optimal treatment approach for IGM, as none seems to be steroids and claimed that this treatment would provide ideal. Treatment options include antibiotics, steroids, better cosmesis and lower recurrence. The surgeon as well methotrexate (MTX), azathioprine, drainage of the wound, as the patient should have patience during the course of wide surgical resection, mastectomy, and expectant man- the disease because it is characterized by slow resolution agement with close follow-up49e54. Aggressive surgery, such and tends to gradually resolve spontaneously2. Observation as wide resection or mastectomy, is an accepted treat- without any therapy, known as expectant conservative ment7,15,55, whereas some recommend a conservative management, is an effective treatment approach63; how- approach17,39. In addition to being therapeutic, surgical ever, close follow-up is essential. If untreated, spontaneous excision provides a definitive diagnosis56. Involvement of regression in up to half of cases has been reported8. Thus oncoplastic surgery, such as mastectomy, followed by Lai et al3 reported complete disease resolution and no autologous breast reconstruction and steroids are alterna- recurrence in 50% of their patients with expectant man- tive treatments for severe and intractable cases33. How- agement. Correlatively, six (60%) of our patients underwent ever, surgical resection can also be associated with expectant conservative management and showed sponta- complications, including recurrence rates as high as 50%, neous complete recovery, as mentioned above. In the poor wound healing, sinus tract or abscess formation, and absence of inflammatory signs in mild disease, expectant disfigurement9,15e17,22,33,40,57e59. None of our patients with management is preferred. If the condition worsens clini- bilateral IGM underwent surgical resection. cally and radiologically, steroids are administered for 6e8 Regarding conservative management, steroids as a pri- weeks at an initial dose of 0.5 mg/kg/d in divided doses mary treatment have been shown to be beneficial for (4 þ 2), which are tapered slowly with clinical improve- shrinking the lesion both pre- and postoperatively in per- ment. As there is a strong tendency for persistence or sisting masses60,61. DeHertogh et al60 first reported that recurrence, surgery should be considered in untreatable high-dose prednisone was more effective in recurrent or cases. refractory cases. Many clinicians recommend an initial For follow-up, all of the patients were invited to our treatment of 30e60 mg prednisone orally, which is tapered mastitis study group for examination once or twice per gradually over several weeks (from 1 week to 22 week until the symptoms resolved. The disease course was months)18,19,22,24,28,40,41,44,52,53,62. In our study, four (40%) followed by routine US at 1- and 3-month intervals. After cases were treated with oral prednisolone for 6 weeks at an significant wound healing, 6-month follow-up US is initial dose of 0.5 mg/kg/d in divided doses (4 þ 2), which preferred. Finally, when the disease had resolved were tapered slowly with clinical improvement. Because completely, annual examination and screening were continued high doses of steroids until complete resolution advised. may be necessary51,60, the patients should be observed Although the diagnosis and management of IGM remain closely for side effects, such as glucose intolerance and challenging, interdisciplinary approaches to this disorder Cushing’s syndrome, as well as , avascular ne- are essential. Unnecessary intervention and delays in the crosis, depression, and cataracts13,20,63. One should also diagnosis and treatment can be avoided by precise radio- take into account relapses following withdrawal of the logical and pathological evaluation. In conclusion, bilateral Bilateral idiopathic granulomatous mastitis 19

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