Specialist Management of Granulomatous Mastitis
Granulomatous mastitis should be managed by a breast surgeon, ideally within a multidisciplinary team that includes specialists in inflammatory breast disease, rheumatology or immunology for immunosuppressive therapy, and plastic surgery for reconstruction when needed. 1, 2
Primary Specialist: Breast Surgeon
The breast surgeon serves as the primary specialist for granulomatous mastitis management, as this condition requires expertise in distinguishing it from inflammatory breast cancer and other breast pathology 3, 1. Breast surgeons coordinate diagnostic procedures including core needle biopsy and manage both surgical and non-surgical treatment options 2.
Multidisciplinary Team Approach
Treatment should be undertaken as part of a multidisciplinary team including surgeons and physicians with an interest in inflammatory breast disease 4. The international consensus on granulomatous lobular mastitis emphasizes that multidisciplinary experts from various specialties should be involved in management decisions 1.
Key Team Members:
Breast surgeons: Perform diagnostic biopsies, surgical excision when indicated, and coordinate overall care 3, 2
Rheumatologists or immunologists: Manage immunosuppressive therapy, particularly when autoimmune markers (RF, ANA, anti-dsDNA) are positive 5. These specialists guide corticosteroid and immunosuppressive treatment protocols 5, 2
Plastic/reconstructive surgeons: Provide reconstruction following radical excision, though immediate reconstruction is not recommended 4. Reconstruction specialists must understand complications associated with residual disease 4
Radiologists: Perform and interpret imaging studies, though radiological imaging has limited ability to differentiate granulomatous mastitis from malignancy 3
Pathologists: Confirm diagnosis through histopathological examination, as granulomatous mastitis is often only definitively diagnosed after surgical excision or core biopsy 3, 1
Referral Patterns
Patients should be referred to specialized centers with expertise in inflammatory breast disease 1, 2. The American Society of Breast Surgeons registry data demonstrates that management is optimized when breast surgeons experienced in inflammatory conditions coordinate care 2.
When to Refer:
Initial presentation with suspected granulomatous mastitis requires referral to a breast surgeon for diagnostic biopsy 3, 1
Patients with severe symptoms or those requiring surgical intervention need immediate breast surgery consultation 2
Cases with positive autoimmune markers (RF, ANA, anti-dsDNA) warrant rheumatology or immunology consultation for steroid therapy 5
Patients requiring radical excision should be evaluated by plastic surgery for reconstruction planning 4
Common Pitfalls
Do not treat presumed mastitis with prolonged antibiotics without tissue diagnosis 6. A history of mastitis not responding to at least 1 week of antibiotics should prompt immediate referral to a breast surgeon for biopsy to exclude inflammatory breast cancer 7, 6.
Avoid misdiagnosis by ensuring histopathological confirmation 3, 5. Granulomatous mastitis frequently mimics inflammatory breast carcinoma both clinically and mammographically, making tissue diagnosis essential 3.
Do not delay immunosuppressive therapy in appropriate cases 2. The ASBrS registry found that immunosuppressive therapy was predictive of symptom improvement or resolution at 1 month (odds ratio 4.22) 2.