Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 1604e1607

Idiopathic granulomatous mastitis: Successful

treatment by mastectomy and immediate
breast reconstruction
Michaela Hladik a,*, Thomas Schoeller b,c, Florian Ensat a,
Gottfried Wechselberger a,c

a
Department of Plastic and Reconstructive Surgery, Hospital of the Barmherzigen Bruder,
Teaching Hospital of the Medical University Salzburg, Kajetanerplatz 1, 5020 Salzburg, Austria
b
Department of Plastic and Reconstructive Surgery, Marienhospital Stuttgart, Boheimstrasse 37, 70199 Stuttgart, Germany
c
University Hospital of Plastic and Reconstructive Surgery, Anichstrae 35, 6020 Innsbruck, Austria

Received 1 February 2011; accepted 9 July 2011

KEYWORDS Summary We describe three women with idiopathic granulomatous mastitis (IGM), a rare,
Idiopathic benign breast disease. It is a chronic inflammatory lesion of the breast and presents with
granulomatous mastitis; the clinical symptoms of inflammation, breast mass and tumorous indurations and ulcerations
Mastectomy; of the skin. Clinical and radiological findings often mimic breast cancer. Histopathologic exam-
Primary reconstruction ination remains the gold standard for the diagnosis. It is a non-malignant entity but it may be
both locally aggressive and recurrent. The treatment of choice is unclear, but surgical excision
and adjunctive treatment with glucocorticoids or antibiotics is described most frequently. We
present three patients with a long history of recurrences that was successfully treated by
mastectomy and immediate breast reconstruction.
2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

Idiopathic granulomatous mastitis (IGM) is a rare, benign
breast disease. The related clinical and radiological features
often mimic those of mammary carcinoma. It is charac-
terised by chronic, necrotising lobulitis of unknown aeti-
ology.1 Diagnosis can only be confirmed by histopathology.
* Corresponding author. Tel.: 43 662 8088 8252; fax: 43 662
8088 8253.
E-mail address: michaela.hladik@bbsalz.at (M. Hladik).
The optimal path for treatment is still unclear. Most patients
have been treated with wide surgical excision, which is
occasionally supported by glucocorticoids or antibiotics.2
The primary problems of IGM are the high rate of recur-
rence and the long duration required for complete resolution
of symptoms. In patients with a long history of recurrence
and failure of common therapy modalities, radical treat-
ment by mastectomy and free-tissue transfer may be the last
option. The purpose of this study is to demonstrate our
experience with this uncommon approach.

1748-6815/$ - see front matter 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2011.07.011
Treatment of idiopathic granulomatous mastitis 1605

Patients and methods

Between May 2005 and October 2005, three women were

referred to our two institutions in Innsbruck and Salzburg
with inflammatory breast disease and the histopathological
diagnosis of IGM. Patient demographics and clinical vari-
ables were examined (including age, prior therapy, number
of pregnancies, lactation, nicotine abuse, use of oral
contraceptives and systemic diseases).
All patients had previously undergone surgery (wide
local excisions) for diagnosis and therapy and all were
treated with antibiotics; however, all showed recurrence.
Abscesses developed continuously and all patients under-
went several excisions, which did not improve their symp-
toms. The period between first detection by the patient
and admission to our department was 3e5 years.
In all three cases, mastectomy and primary reconstruc-
tion of the breast were planned. Figure 2 Postoperative view, 5 months after skin-sparing
mastectomy and recurrence of IGM.

Case report
A 27-year-old female smoker was referred to our Depart-
ment of Plastic and Reconstructive Surgery. The patient
had a 30-month history of inflammatory left-breast disease
consisting of breast pain, mass and induration. She was
treated with long-term antibiotic regimes and multiple
excisions that did not improve her symptoms. Histopa-
thology showed IGM with no evidence of carcinoma or
infective organisms, and she was referred to our care for
consideration of mastectomy.
At the time of presentation, the patient had a persistent
wound in the upper pole of the left breast, which showed
no signs of healing, and nipple retraction (Figure 1). There
was no involvement of the contralateral breast and no
lymphadenopathy. The patient had never been pregnant
before and had never taken oral contraceptives.
A skin-sparing mastectomy and primary reconstruction
with a transverse myocutaneous gracilis (TMG) flap were
performed. However, this initial treatment was ineffective
because abscesses recurred from residual breast tissue
(Figure 2). Five months later, we undertook a modified
mastectomy, including all involved soft tissues and all
breast glandular tissue and primary reconstruction with
a deep inferior epigastric perforator (DIEP) flap. The
reconstruction was completed by trimming the flap, nipple
reconstruction and nipple areolar complex tattooing, which
collectively yielded a satisfactory result (Figure 3).
Results
Patient age ranged between 27 and 33 years (mean, 30.3
years); accordingly, all women were of reproductive age.
The average follow-up period was 58 months. The main
symptoms, which were observed during a thorough physical
examination, were breast lump, induration and pain in the
breast complicated by abscesses, superficial skin necrosis
and fistula formations. Nipple inversion was observed in one
patient. Contralateral involvement was seen in one case.
The duration between the first manifestation of symp-
toms and presentation at our department varied from 3 to 5

Figure 3 Postoperative view, 4 years and 5 months after

Figure 1 Patient with IGM of the left breast. mastectomy and DIEP-flap reconstruction.
1606
years. All patients had undergone multiple excisions sup-
ported by antibiotic therapy. In addition, all women
reported intake of the prolactin inhibitor cabergoline
(Dostinex) due to suspicion of a prolactinoma, which was
only confirmed in one case. However, even in this case,
treatment with cabergoline yielded no improvement.
Only one woman provided a history of gravidity and
breast feeding. The symptoms occurred 1 month after
ablactation of the patients last child. Due to the suspicion
of breast cancer, mammography was performed in all
cases, but histopathology was necessary to confirm IGM.
In one case, we performed a modified mastectomy and
DIEP-flap reconstruction. In one case, we initially per-
formed a skin-sparing mastectomy and TMG-flap recon-
struction with subsequent modified mastectomy and DIEP-
flap reconstruction due to recurrence. The third patient
underwent a skin-sparing mastectomy and immediate
reconstruction with a TMG flap. In two cases, mastopexy of
the contralateral breast was performed. In conclusion, all
cases concluded with aesthetically pleasing results and
without apparent recurrence.
Discussion
In this article, we report our experience in patients with
recurrent IGM treated by mastectomy and primary micro-
surgical free-tissue breast reconstruction.
IGM is a rare, benign entity of unknown aetiology. It was
first described by Kessler and Woloch in 1972.3 This entity
may manifest in several ways, including a mass in the
breast, induration, breast abscess and fistula formation.4,5
IGM usually occurs in women of child-bearing age.6,7
However, female IGM cases ranging from 11 to 83 years of
age have been reported.8,9 Moreover, IGM is most
frequently associated with recent pregnancy and lacta-
tion,5,10 although there are also some cases without any
history of childbirth.8 Usually, it is a unilateral condition,9
but occasionally the involvement is bilateral.11,12
However, the aetiology is still unknown and, conse-
quently, the management of this disease is challenging.
Moreover, all treatment entities are associated with
recurrence rates of 16e50% that might keep the patient
under medical care for a prolonged period.8,9 The treat-
ment options recommended in other studies implemented
most frequently wide are excision of the affected tissue,
the use of glucocorticoids or the administration of anti-
biotics.2,13e15 The use of methotrexate monotherapy has
also been reported.16 These treatment modalities reported
in the literature are all associated with a certain rate of
recurrence. In the case reported above, granulomatous
deposits from the residual breast tissue after subcutaneous
mastectomy probably caused the recurrence, underlining
the necessity of mastectomy in certain patients. This case
highlights the fact that, in these challenging cases, less
sometimes is not better. The treatment algorithm pre-
sented in this study is uncommon, but all patients in our
series had undergone multiple surgical procedures and
conservative treatment without success before they were
transferred to our unit.
Previous surgical attempts were ineffective, caused
massive contour deformities of the breast and abscesses
M. Hladik et al.
developed continuously in all patients. Thus, all of them
were accessible to this radical approach comprising
mastectomy and primary breast reconstruction with autol-
ogous tissue.
Nowadays, free-flap breast reconstruction is a safe and
well-established standard procedure in reconstructive
surgery with high success rates and high patient satisfac-
tion. The inconspicuous and well-hidden donor sites
provided by the TMG flap and DIEP flap make patients
amenable to this complex procedure.
Conclusion
The optimal management of IGM is still controversial.
Patients undergo multiple treatment modalities before
presentation in a plastic surgery unit. The overall trend
among these patients is a long history of recurrence
accompanied by an enormous psychological burden neces-
sitating a reliable, safe and quick solution. In such selected
cases, mastectomy followed by primary free-flap breast
reconstruction offers a valuable option for quick patient
rehabilitation.
Ethical approval
The research protocol was approved by the local Ethical
Committee.
Funding
None.
Conflict of interest
None.
References
1. Imoto S, Kitaya T, Kodama T, Hasebe T, Mukai K. Idiopathic
granulomatous mastitis: case report and review of the litera-
ture. Jpn J Clin Oncol 1997;27:274e7.
2. Azlina AF, Ariza Z, Arni T, Hisham AN. Chronic granulomatous
mastitis: diagnostic and therapeutic considerations. World J
Surg 2003;27:515e8.
3. Kessler E, Wolloch Y. Granulomatous mastitis: a lesion clini-
cally simulating carcinoma. Am J Clin Pathol 1972;58:642e6.
4. Erhan Y, Veral A, Kara E, et al. A clinicopathologic study of
a rare clinical entity mimicking breast carcinoma: Idiopathic
granulomatous mastitis. Breast 2000;9:52e6.
5. Ocal K, Dag A, Turkmenoglu O, Kara T, Seyit H, Konca K.
Granulomatous mastitis: clinical, pathological features, and
management. Breast J 2010;16:176e82.
6. Gal-Gombos EC, Esserman LE, Odzer SL, Weisberg S, Wilson C,
Poppiti Jr RJ. Granulomatous mastitis: diagnosis by ultrasound-
guided core biopsy. Breast J 2001;7:129e30.
7. DeHertogh DA, Rossof AH, Harris AA, Economou SG. Prednisone
management of granulomatous mastitis. N Engl J Med 1980;
303:799e800.
8. Lai EC, Chan WC, Ma TK, Tang AP, Poon CS, Leong HT. The role
of conservative treatment in idiopathic granulomatous
mastitis. Breast J 2005;11:454e6.
Treatment of idiopathic granulomatous mastitis
9. Bani-Hani KE, Yaghan RJ, Matalka II, Shatnawi NJ. Idiopathic
granulomatous mastitis: time to avoid unnecessary mastecto-
mies. Breast J 2004;10:318e22. 13.
10. Salam IM, Alhomsi MF, Daniel MF, Sim AJ. Diagnosis and
treatment of granulomatous mastitis. Br J Surg 1995;82: 14.
214.
11. Taghizadeh R, Shelley OP, Chew BK, Weiler-Mithoff EM. Idio-
pathic granulomatous mastitis: surgery, treatment, and 15.
reconstruction. Breast J 2007;13:509e13.
12. Taylor GB, Paviour SD, Musaad S, Jones WO, Holland DJ. A 16.
clinicopathological review of 34 cases of inflammatory breast
disease showing an association between corynebacteria
1607
infection and granulomatous mastitis. Pathology 2003;35:
109e19.
Dixon JM, Chetty U. Diagnosis and treatment of granulomatous
mastitis. Br J Surg 1995;82:1143e4.
Tse GM, Poon CS, Law BK, Pang LM, Chu WC, Ma TK. Fine
needle aspiration cytology of granulomatous mastitis. J Clin
Pathol 2003;56:519e21.
Moore GE. Diagnosis and treatment of granulomatous mastitis.
Br J Surg 1995;82:1002.
Schmajuk G, Genovese MC. First report of idiopathic granulo-
matous mastitis treated with methotrexate monotherapy. J
Rheumatol 2009;36:1559e60.