Granulomatous lobular mastitis

Granulomatous lobular mastitis is a disease that mostly occurs in young postpartum women. The main symptom is breast lumps. Such symptoms are actually relatively easy to detect for healthy female friends. As long as you pay more attention to breast health, you can know in time whether there is any disease.

Clinical manifestations

(1) Most of them are young multiparous women, and most of them develop the disease within 6 years after delivery. The average course of the disease is 4.5 months, and the average age is 33 years old. Unmarried and childbearing patients are mostly related to drugs or pituitary prolactinoma.

(2) The main clinical manifestation is breast lumps, which appear suddenly (suddenly), often with a huge lump or enlargement of the entire breast overnight, or a smaller lump that rapidly enlarges. The initial site is generally far away from the areola, but it quickly spreads to the areola. The mass is obviously pleomorphic, or extends in a pseudopodia-like manner, or spreads laterally through the areola to the corresponding part. After 1-2 weeks, a small area of ​​redness and swelling appeared on the surface of the lump, which I called "crane's crown red", and scattered abscesses and multi-layer sinus tracts formed inside.

(3) Most cases are accompanied by pain, even severe pain. Some people even have pain as the first symptom and do not discover the lump until several days to a month later. Painless lumps account for only 9%, so the incidence and severity of pain or tenderness are significantly higher than breast cancer.

The body temperature is generally normal, but some people may have a low fever or a high fever for a few days. If an infection occurs after puncture, the high fever may not subside.

(4) The disease progression is non-progressive, but intermittent and staged, with remission periods of several months and up to 3 years. The self-limitation and remission of the disease are often mistaken for efficacy or cure, and then sudden attacks may occur before menstruation, when angry or tired.

(5) The nipple is normal or inverted after the onset of the disease. Granuloma GLM has nothing to do with nipple morphology. The lesion often invades the areola from the periphery but rarely involves the nipple.

(6) After incision and drainage, there is not much yellow pus, but mostly yellow water or rice soup-like, bloody pus or more bleeding than pus, which is different from acute suppurative mastitis. After several dressing changes, bright red granulation tissue appeared in the wound, which was completely different from tuberculous latent ulcer.

(7) 30% of “granulomas” are accompanied by obvious generalized joint swelling and pain or lower limb nodular erythema, that is, rheumatoid changes. Some patients have abnormal antinuclear antibody spectrum and positive rheumatoid factor. It seems to support that "granuloma" is an autoimmune disease, but serological evidence is currently lacking.

(8) 20% of patients have hyperprolactinemia. The increase in prolactin is usually transient and lasts for 1-2 months. I speculate that prolactin acts as a trigger or ignition at the beginning of the disease.

(9) There is a tendency for the disease to occur bilaterally. About 11% of patients have breast cancer simultaneously or successively, with the interval usually within one year.

diagnosis

Clinically, based on "3 3s in medical history, the lump occurs on the outside. Pain first, then redness and swelling, and red spots on the legs." That is, the patients are in their 30s, the youngest child is 2-3 years old, and the disease course is 3-4 months. The lumps usually originate around the breast, away from the areola. It is often accompanied by pain and obvious tenderness. Patchy redness and swelling quickly appear on the surface of the mass, followed by suppuration, rupture and pus discharge, and clinical manifestations such as nodular erythema or multiple joint pains in the lower limbs. The clinical diagnosis of typical granulomatous GLM is not difficult. However, the diagnosis of early granulomas is very difficult, especially those lumps that are painless, non-red and swollen, which are often misdiagnosed as fibrocystic fibrosis or breast cancer. However, color Doppler ultrasound and mammography examinations lack specificity, so the misdiagnosis rate can be as high as 100%. There are not many cases where fine needle aspiration cytology can make a diagnosis of granuloma, and generally it can only help differentiate between cancer and inflammation. Hollow core needle or Mammotome biopsy with pathological section diagnosis is the best method, and the final gold standard for diagnosis is postoperative pathological diagnosis.

treat

There are differences in the treatment options for granulomatous leukemia (GLM), and the current treatment options are at the "blind men groping in the dark" stage. The earliest popular treatment was corticosteroids, with a daily dose of 30-40 grams of prednisone and an average duration of 4.7 months. It is suitable for early cases with a mass less than 4 cm in diameter, that is, the stage without abscess and sinus tract. The characteristics of hormone therapy are rapid onset and good efficacy. The therapeutic effect weakens after a period of time, and the symptoms rebound rapidly after reducing the dosage or stopping the medication, and eventually the condition worsens and becomes difficult to control. There are indeed reports of cured cases in the literature, but the number of cases is small and the follow-up time is not long, so it is difficult to confirm the long-term efficacy. The biggest problem is that the side effects of corticosteroids are obvious, including excitement, central obesity, decreased glucose tolerance, osteoporosis and even femoral head necrosis. Long-term use of hormones for more than one month is not conducive to wound healing and increases the risk of intraoperative bleeding, cortical dysfunction, etc. Therefore, hormone therapy should be used for appropriate indications, that is, early cases without abscesses and sinus tracts. The trial treatment time should not exceed 2 weeks. If the effect is not good, the dosage should be reduced immediately and the drug should be gradually stopped.

Corticosteroids are effective and have a significant effect, which can only prove that granuloma is an autoimmune disease, but it should not be used as the first choice. It is now mostly used for postoperative adjuvant treatment to reduce recurrence, or for severe cases that are difficult to control.

According to our experience of more than 300 surgeries, early surgery is very effective, with a recurrence rate of less than 2% and the appearance can be guaranteed. Once the disease invades the skin, it will become red and swollen, the recurrence rate will increase significantly, and the appearance will be severely damaged. Although granulomatous leukemia (GLM) is a benign disease, it is highly invasive and recurrent locally. Sporadic residual lesions can disseminate and implant, and have a certain tendency to local malignancy. The effectiveness of surgical treatment is directly related to the surgical method. The so-called lumpectomy, segmental excision, and extended excision are not suitable for granuloma.

Granuloma GLM is a sterile inflammation, and antibiotics are futile. However, many doctors, seeing redness, swelling and pus, habitually think "if it's inflammation, use anti-inflammatory drugs, and if it's anti-inflammatory, use antibiotics." As a result, they blindly use a variety of antibiotics, even Tylenol, which in most cases is abuse and waste. Antibiotics should only be used appropriately when the white blood cell count is high, fever is present, and concurrent infection is considered.

For any disease that is difficult to treat with Western medicine, Chinese medicine is always recommended. Traditional Chinese medicine is a dialectical treatment method. "Use the right medicine for the right syndrome" is a universal principle of traditional Chinese medicine. There is no need to distinguish whether it is a granuloma or a mastitis. Different diseases can be treated with the same method, so traditional Chinese medicine and Chinese herbal medicine have a broad market. Chinese medicine, taken orally or applied externally, can indeed alleviate the symptoms in some cases and can even temporarily cure them. In terms of treatment methods, we should follow the dialectical principles of sores and ulcers. Zhang Shanlei, a senior ulcer doctor, said: "In ulcer dialectics, we must first distinguish between yin and yang. If there is no mistake in yin and yang, there will be no difference in treatment." Granuloma GLM is a chronic inflammatory ulcer, which is actually a Yin syndrome, or there is Yang in Yin, but it is definitely not a Yang syndrome ulcer. It is not suitable for heavy doses of clearing heat and detoxifying. Some people use Chaihu medicine to soothe the liver and promote blood circulation, but long-term use will make the patient more tired and weak, which will make the condition worse. Some people reuse pangolins, but their effectiveness has not been proven clinically. We recommend using Lithospermum officinale plus Yanghe Decoction, which is a famous prescription used by Wang Hongxu in the Qing Dynasty to treat yin sores. Lithospermum officinale lowers prolactin and inhibits inflammation. It was originally used to treat kidney deficiency type breast hyperplasia. In 2007, it was used to treat granuloma. It was found to be effective quickly, able to reduce tumors, promote wound healing, and create the best time for surgery. Taking the medicine for at least half a year after surgery can reduce the chance of recurrence on the affected side and disease on the contralateral side. It has now become our routine medication.

Others use triple anti-tuberculosis drug trials based on the principle of extrapulmonary non-tuberculous mycobacterial infection if no tuberculosis bacilli are found. According to our observations, it is basically ineffective and contrary to the use of corticosteroids for treatment. As we all know, corticosteroids are contraindicated for tuberculosis.