What is the treatment for refractory breast cancer of the left breast?

Treatment of Refractory Idiopathic Granulomatous Mastitis (IGM) of the Left Breast

For refractory idiopathic granulomatous mastitis, corticosteroid therapy is the primary treatment approach, with surgical intervention reserved for cases with complications such as abscess formation, fistulae, or persistent wound infection. 1

Initial Diagnostic Confirmation

Before initiating treatment for refractory IGM, ensure proper diagnosis has been established:

• Core needle biopsy is essential to confirm granulomatous inflammation and exclude infectious etiologies (bacterial, fungal, tuberculous) and malignancy, as IGM mimics breast cancer clinically and radiologically 2, 1
• Tissue cultures must be obtained to rule out infectious causes, particularly tuberculosis, which requires specific antimicrobial therapy rather than immunosuppression 1
• Fine needle aspiration alone is insufficient; core biopsy provides more definitive histopathologic diagnosis 1

Primary Treatment Algorithm for Refractory IGM

First-Line: Corticosteroid Therapy

Systemic corticosteroids have demonstrated efficacy in treating IGM and should be the initial approach for refractory cases 1:

• Oral corticosteroids are the standard systemic approach 1
• Intralesional steroid injections can be considered as an alternative route of administration 3
• Duration and dosing should be sufficient to achieve clinical response, though specific protocols vary 1

Second-Line: Topical Immunomodulation

For cases that remain refractory to systemic steroids, topical imiquimod (an immunomodulator) has shown promise 4:

• Applied topically for 4-7 weeks 4
• Caution: skin ulceration may occur but typically resolves safely 4
• This represents an emerging treatment option with limited adverse effects compared to systemic therapy 4

Surgical Intervention Timing

Surgery should NOT be the initial approach for uncomplicated refractory IGM 1:

• Reserve surgical excision for specific complications only: abscess formation, fistulae, or persistent wound infection that fails medical management 1
• Wide local excision or lumpectomy may be required when medical therapy fails and complications develop 1
• Expectant management with close surveillance is appropriate in select cases, as 50% may achieve spontaneous resolution over 14.5 months, though this is less applicable to truly refractory cases 5

Important Clinical Pitfalls

Common Diagnostic Errors

• IGM is frequently misdiagnosed as breast cancer on clinical examination, mammography, and even MRI 2, 1
• Physical examination and imaging alone are insufficient; histopathologic confirmation is mandatory before initiating immunosuppressive therapy 1
• Failure to exclude tuberculosis before starting corticosteroids can lead to disease progression, as tuberculous mastitis requires 6 months of antituberculous therapy 1

Treatment Considerations

• Antibiotics alone are ineffective for IGM; refractory mastitis despite antibiotic therapy should prompt consideration of IGM 2
• The disease course is often prolonged with multiple recurrences despite treatment 2
• Pregnancy status matters: corticosteroid therapy should be deferred until after delivery if the patient is pregnant 1
• Recurrence after initial steroid response may occur (documented at 11 months), requiring repeat corticosteroid therapy 1

Monitoring and Follow-Up

• Close regular surveillance is essential throughout the treatment course 5
• Clinical assessment should monitor for treatment response and development of complications requiring surgical intervention 1
• Imaging follow-up (ultrasound primarily) helps assess disease progression or resolution 2, 1

Key Distinguishing Features from Breast Cancer Treatment

The evidence provided regarding metastatic breast cancer treatment 3, 6, 7, 8 is not applicable to IGM, which is a benign inflammatory condition, not a malignancy. The critical distinction is that IGM requires immunosuppression or observation, not oncologic therapy 2, 5, 1.