Ragheed Al-Mufti

Should we manage all cases of granulomatous mastitis conservatively? A 14 year experience.

To the Editor: Granulomatous mastitis (GLM) is a rare localized benign inflammation of the breast, presenting commonly as a painful mass in young women with a history of recent breast-feeding (1,2). It can often mimic breast carcinoma both radiologically and clinically. The histologic presence of non caseating granulomas confined within breast lobules together with negative microbiologic finding, including mycobacteria and fungal cultures often confirms diagnosis (1,2). Steroids, surgery, and antibiotics have been used with varying degrees of success as recurrence and a chronic clinical course are deemed to be more likely without intervention (2,3). We present our experience of managing GLM conservatively over the last 14 years. We identified all patients presenting with GLM retrospectively from the histopathologic archival data base between 1996 and 2010. Hospital records were reviewed, patient demographics, presenting complaint and history, relevant obstetric history, initial treatment, recurrence, length of follow-up, and discharge from clinic were recorded. The radiologic and microbiologic results including tuberculosis and fungal infections were also compiled for each patient. For those patients that had been discharged from clinic, a telephone questionnaire was conducted inquiring specifically if there had been further recurrence of disease with treatment being sought at another hospital. A total of 17 patients were identified with GLM. One patient was excluded due to inaccessible hospital records. Telephonic consultation was possible for 13 patients. The median age of presentation was 37 (21–50) years. Patients were of multiethnic origin, mostly being Africo-Carribean or Asian (n = 9, 56.3%). Three (18.8%) of the patients had previously been treated for benign breast lumps affecting the other breast. There were 13 parous patients (81.3%) with only one patient being pregnant, three patients had delivered less than 12 months and eight patients had been pregnant more than 3 years before presentation. None of the patients were breast-feeding, but a majority of the patients (n = 10, 60%) had breast-fed previously with two having breast-fed within the last 4 months from presentation. The left breast was affected in 10 of 16 patients and there was no bilateral breast involvement. The presented complaints were lump (n = 16), pain (n = 12), erythema (n = 4), and a discharging sinus in five patients. Mammography and ultrasound were done for 11 patients with three patients having only an ultrasound and two patients having a mammogram alone. Ultrasound suggested a suspicious lesion, meriting further investigations, in nine (81.8%) patients. The mammogram showed a nonspecific density in six patients with one showing suspicious microcalcifications. All patients (n = 16) underwent diagnostic core biopsy confirming GLM on histology. Excisional biopsy was not performed in any of the patients. After the diagnosis of GLM was made further core biopsies were taken. Core biopsies from three patients yielded mycobacteria tuberculosis after culture and from one patient it was Aspergillus Fumigatus. All patients received up to 2 weeks of antibiotics initially prior to diagnosis. No further treatment was given to any of the patients until TB and fungal cultures were reported after 12 weeks. At that point, three patients were commenced on anti-tuberculosis treatment and one on oral systemic anti-fungal therapy. The remaining 12 patients were diagnosed with idiopathic GLM. Two patients who had substantial discharging sinuses were then treated with 50–60 mg of Prednisolone for 6 months and then reducing dose over a further 6 months. The remaining 10 patients were advised to have no medical treatment and attended our follow-up clinic at 6–12 weekly intervals till complete regression of the disease. Symptoms resolved within 6–12 months in seven patients. The Address correspondence and reprint requests to: Ms Parveen Jayia, Apartment 30 The School House, 69 Tollington Road, Islington, N7 6DW, UK, or e-mail: parveenjayia@gmail.com.

Validation of an oncoplastic breast simulator for assessment of technical skills in wide local excision.

Simulation enables safe practice and facilitates objective assessment of technical skills. However, simulation training in breast surgery is rare and assessment remains subjective. The primary aim was to evaluate the construct validity of technical skills assessments in wide local excision (WLE).

A clinical "near miss" highlights risk management issues surrounding ultrasound-guided and wire-localised breast resections

BackgroundThe introduction of the National Health Service (NHS) Breast Screening Programme has led to a considerable increase in the detection of impalpable breast cancer. Patients with impalpable breast cancer typically undergo oncological resection facilitated either by the insertion of guide wires placed stereo-tactically or through ultra-sound guided skin markings to delineate the extent of a lesion. The need for radiological interventions on the day of surgery adds complexity and introduces the risk that a patient may accidentally transferred to the operating room directly without the image guidance procedure.Case reportA case is described of a patient who required a pre-operative ultrasound scan in order to localise an impalpable breast cancer but who was accidentally taken directly to the operating theatre (OR) and anaesthetised without pre-operative intervention. The radiologist was called to the OR and an on-table ultrasound was performed without further consequence.ConclusionIt is evident that breast cancer patients undergoing image-guided resection are exposed to an additional layer of clinical risks. These risks are not offset by the World Health Organisation surgical safety checklist in its present guise. Here, we review a number of simple and inexpensive changes to the system that may improve the safety of the breast cancer patient undergoing surgery.

Best-practice care pathway for improving management of mastitis and breast abscess: Management of mastitis and breast abscess

Surgical subspecialization has resulted in mastitis and breast abscesses being managed with unnecessary admission to hospital, prolonged inpatient stay, variable antibiotic prescribing, incision and drainage rather than percutaneous aspiration, and loss to specialist follow‐up. The objective was to evaluate a best‐practice algorithm with the aim of improving management of mastitis and breast abscesses across a multisite NHS Trust. The focus was on uniformity of antibiotic prescribing, ultrasound assessment, admission rates, length of hospital stay, intervention by aspiration or incision and drainage, and specialist follow‐up.

Streamlining Decision Making in Contralateral Risk-Reducing Mastectomy: Impact of PREDICT and BOADICEA Computations

IntroductionPatients with sporadic breast cancer (BC) have low contralateral breast cancer risk (CLBCR; approximately 0.7% per annum) and contralateral prophylactic mastectomy (CPM) offers no survival advantage. CPM with autologous reconstruction (AR) has major morbidity and resource implications.ObjectiveThe aim of this study was to review the impact of PREDICT survival estimates and lifetime CLBCR scores on decision making for CPM in patients with unilateral BC.MethodsOf n = 272 consecutive patients undergoing mastectomy and AR, 252 were included. Five- and 10-year survival was computed with the PREDICT(V2) online prognostication tool, using age and clinicopathological factors. Based on family history (FH) and tumor biology, CLBCR was calculated using validated BODICEA web-based software. Survival scores were correlated against CLBCR estimates to identify patients receiving CPM with ‘low’ CLBCR (< 30% lifetime risk) and poor prognosis (5-year survival < 80%). Patients with ‘high’ CLBCR receiving unilateral mastectomy (UM) were similarly identified (UK National Institute of Health and Care Excellence [NICE] criteria for CPM, ≥ 30% lifetime BC risk). Justifications motivating CPM were investigated.ResultsOf 252 patients, 215 had UM and 37 had bilateral mastectomy and AR. Only 23 (62%) patients receiving CPM fulfilled the NICE criteria. Of 215 patients, 5 (2.3%) failed to undergo CPM despite high CLBCR and good prognosis. CPMs were performed, at the patient’s request, for no clear justification (n = 8), contralateral non-invasive disease, and/or FH (n = 5), FH alone (n = 4) and ipsilateral cancer recurrence-related anxiety (n = 3).ConclusionIn the absence of prospective risk estimates of CLBCR and prognosis, certain patients receive CPM and reconstruction despite modest CLBCR, yet a proportion of patients with good prognoses and substantial risk are not undergoing CPM.