الفهرس 
TitleOnly 14 pages are availabe for public view
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Abstract
Idiopathic granulomatous mastitis (IGM) is a rare, benign, chronic, inflammatory lesion of the breast, affecting females in the reproductive age group, with most patients found in Mediterranean area and Middle East. Till now; its etiology has not been fully elucidated, but milk extravasation from lactiferous ducts is thought to be an initiating factor in its pathogenesis, that triggers an autoimmune reaction leading to nonspecific lobulitis and granuloma formation. Clinical picture of the disease includes painful inflammatory breast mass, which might be associated with abscess, ulcer, sinus openings, peau d‟orange of the overlying skin or scars of previous abscesses drainage. Diagnosis of IGM should include core needle biopsy for histopathologic examination, culture and sensitivity test to exclude other bacterial infections and tests for Mycobacterium T.B. detection either by Zeihl Nelseen stain or tissue PCR. Differential diagnosis from other causes of specific granulomatous mastitis and cancer breast should be clarified. Until now, no consensus is available for the management of IGM, as some medical schools prefer medical treatment while others refer to surgery.
The current study is trying to support the idea of complete wide local surgical excision of the diseased areas of the breast; for patients who have not responded to medical treatment, without much affection of the breast aesthetic appearance. This mandates in some cases to resect large volumes ranging between 20-50% of the total breast size; which result in breast distortion and low patient satisfaction; especially that the affected females are young aged.
The idea is to apply therapeutic mammoplasty techniques used in conservative cancer breast surgery, for management of idiopathic granulomatous mastitis unresponsive to medical therapy. The main concern in this study is to provide a treatment algorithm as a nucleus for future management guidelines of the disease.
The aim of the current study is to evaluate surgical treatment for IGM prospectively using therapeutic mammoplasty techniques in terms of postoperative complications, recurrence and patient satisfaction, and to aid in etiology guiding through its experimental aspect on rats.
In the current study; 50 female patients affected with IGM were included, whom response to steroid treatment was limited or absent, with moderate to large breasts (cup B or more), and masses occupying 20-50% of their breast sizes.
Preoperative work up included core needle biopsy for histopathologic examination, culture and sensitivity test to exclude other bacterial infections and tests for Mycobacterium T.B. detection by Zeihl Nelseen stain or tissue PCR if there was doubt in diagnosis. Seven operative therapeutic mammoplasty techniques were used; namely round block, medial and lateral mammoplasties, superior and inferior mammoplasties, batwing excision and vertical mammoplasty. Postoperatively; patient follow up for 12 months was done at 1.5, 3,6 and 12 months intervals, for detection of postoperative complications and postoperative recurrence. Patient satisfaction was assessed at 6th month visit by asking the patients to fill the Kyungpook National University Hospital (KNUH) breast reconstruction satisfaction questionnaire.
Summary
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In the experimental aspect of the present study, we tried to explore some of theories that explain the etiology of IGM; namely the unknown microbiological agent and repeated trauma theories. This was done on ten mature female rats aged 12-16 weeks, which divided into 2 groups. The first group was injected with affected females‟ puss in order to test the unknown microbiologic agent theory; in a trial to induce infection. On the other hand, the second group was subjected to repeated needle trauma to their teats; to test for repeated trauma theory.
In the current study, the mean age at presentation was 33 years. Ninety eight percent of patients had history of previous pregnancy. Median number of full term pregnancies of parous females was 3. Median duration since last pregnancy was 40.0 months. The majority (80%) of the affected patients in this study had history of breast feeding with a median duration of 17 months. Contraceptive methods were commonly used (84.0%) at a time before disease presentation; the most common of them (52%) was the non-hormonal intrauterine device (IUD), and the vaginal ring was the least (4%). Oral contraceptive pills (OCP) used in 12.0% of the study group. None of the affected females was an active smoker.
In the scope of the clinical presentation of our patients; equal distribution of right and left sides was found, with the upper lateral quadrant was the most prevalent site of affection. Most of our patients had their mass sizes reduced after preoperative steroid therapy, while 40% has not. Only 2 patients had developed complications during therapy mandating cessation of treatment.
In a descending order of frequency, the most commonly used technique in our study was round block excision followed by racket mammoplasty (medial and lateral mammaplasties), inferior pedicle mammoplasty, superior pedicle mammoplasty, batwing excision and the least one was the vertical mammoplasty technique.
In the present study, minor wound dehiscence (40%) constituted the most frequent postoperative local complication, while nipple areola complex transient venous congestion was the least (2%). The most important postoperative complication in this current study was the disease recurrence, which contributed to 4% of the included patients. For the patient satisfaction; half of the study group obtained mean percent score above 75%. This indicates high patient satisfaction scores in this study.
In the experimental aspect of the current study, ten mature female rats were included. After 8 weeks, excisional biopsies were taken from puss injected, needle traumatized and the saline injected control teats. On histo-pathologic examination, neither significant histologic difference between all treated teats nor granuloma formation in puss injected or needle traumatized rats‟ teats, denoting failure of disease induction. This might attests that microbiologic and traumatic etiologies are less acceptable pathogenesis theories.