Granulomatous Mastitis Treatment in Ankara, Turkey

Granulomatous mastitis is a rare condition that presents as a chronic and inflammatory disease of the breast. It is mostly seen in women of childbearing age and manifests with a painful breast mass, redness, and swelling. The diagnosis is confirmed by clinical evaluation and biopsy.

In the treatment of granulomatous mastitis, medical therapy is generally preferred. Inflammation is controlled with antibiotics, corticosteroids, or immunosuppressive medications. Surgical intervention is considered in cases that do not respond to treatment.

Due to the long course of the disease and the risk of recurrence, patients with granulomatous mastitis should be monitored regularly. During the treatment process, the development of abscess or fistula in the breast tissue should be followed closely.

Differential diagnosis in granulomatous mastitis is important because it may be confused with malignant diseases such as breast cancer. With accurate diagnosis and an individualized treatment approach, complications of the disease can be minimized and quality of life can be maintained.

You can contact Prof. Dr. Ebru Soy, one of the doctors performing Granulomatous Mastitis Treatment in Ankara, to get information about Granulomatous Mastitis Treatment prices, the process, and the hospital where Granulomatous Mastitis Treatment is performed.

What Is Granulomatous Mastitis?

Granulomatous mastitis is a rare disease that develops due to a chronic, benign but inflammatory process in breast tissue. It is generally seen in women of childbearing age, and although the exact cause is unknown, it is thought to be associated with an immune system response.

Who is granulomatous mastitis most commonly seen in?

This condition primarily occurs in young women of childbearing age. Having recently given birth is one of the most commonly associated situations. Some factors thought to play a role in the development of the disease include:

• Recent history of pregnancy or childbirth
• Use of birth control pills
• Elevated milk hormone (prolactin)

Although the average age of occurrence is around the 40s, it can also be seen in much younger or older ages. In recent years, an increase in the frequency of this disease has been noted, especially in certain geographies such as Turkey.

Why does this type of mastitis occur and what is its relation to the immune system?

Although the exact cause of the disease is unknown, the strongest theory is that this is an autoimmune response. In other words, the body’s immune system somehow becomes “confused,” perceives its own breast tissue as a foreign substance, and starts attacking it.

It is thought that this disease may not be only a local problem limited to the breast, but sometimes part of a broader immune system dysregulation. Although rare, in some severe cases inflammatory reactions may also be seen elsewhere in the body.

• Painful red swellings on the legs (Erythema Nodosum)
• Joint pain (Arthritis)

This systemic connection is important from a surgical perspective. If the disease is caused by an underlying systemic immune problem, simply removing the breast mass surgically (wide local excision) will not solve the problem. This also explains why the disease recurs at such a high rate.

What is the gold standard in diagnosing granulomatous mastitis?

For a definitive diagnosis of granulomatous mastitis and to distinguish it from all other dangerous diseases, the gold standard is pathological examination. That is, it is essential to take a biopsy from the suspicious breast mass and examine this tissue under a microscope. Pathologists look for special clusters of inflammation (granulomas) that are “non-caseating” (i.e., without the cheese-like tissue necrosis seen in tuberculosis) and located around the milk glands (lobules).

Another very critical distinction is made in this examination: Cystic Neutrophilic Granulomatous Mastitis (CNGM). This is a rare subtype of the disease and is often associated with a specific type of bacterium called Corynebacterium. If there are findings in the pathology report suggesting this bacterium, the treatment plan changes completely. In this case, not cortisone but specific and long-term antibiotic therapy is required.

Why is having a biopsy so vital?

The necessity of performing a biopsy during the diagnostic process is an indisputable rule. Before starting treatment, biopsy is our only safeguard to exclude two very dangerous conditions.

Excluding Cancer: Granulomatous mastitis frequently mimics breast cancer on both physical examination and imaging (ultrasound, mammography), especially “Inflammatory Breast Cancer.” Without a biopsy, the risk of missing a cancer by assuming it is a benign inflammation cannot be taken.

Excluding Infection: The most common treatment for this disease is systemic cortisone or immunosuppressive drugs. If the patient actually has an infection such as Breast Tuberculosis (Mammary Tuberculosis) that can produce similar findings, and cortisone treatment is started without recognizing this, it may cause the tuberculosis infection to worsen significantly and spread throughout the body.

Therefore, biopsy serves as the most critical “safety filter” that guides treatment.

What are the most common complaints of patients with granulomatous mastitis?

This disease can present clinically in very different ways. The reasons patients most commonly seek medical care include:

• A hard palpable breast mass (most common)
• Severe, throbbing breast pain (mastalgia)
• Abscess formation in the breast
• Abscess opening to the skin (fistula)
• Non-healing, chronic discharge

Which external appearance changes in the breast raise concern for cancer?

As the disease progresses, serious changes may also occur in the external appearance of the breast. These findings are cancer-mimicking signs that worry patients the most and require urgent medical attention.

• Widespread redness of the skin
• Swelling and edema in the breast
• Skin retractions or sores (ulceration)
• Nipple inversion
• “Orange peel” appearance (Peau d’orange)

Especially the “orange peel” appearance is also a classic finding of inflammatory breast cancer, so it is vital to consult a general surgery specialist as soon as these symptoms are seen.

Why is it important to distinguish granulomatous mastitis from breast tuberculosis?

Breast tuberculosis (BT), especially in regions where tuberculosis is common (endemic), is another mimicker that must be considered. Distinguishing between these two diseases is vital because their treatments are completely opposite.

In Granulomatous Mastitis (IGM), the immune system is suppressed (Cortisone).

In Breast Tuberculosis (BT), the infection is eradicated (Anti-tuberculosis drugs).

Giving cortisone to a BT patient by mistake worsens the infection. Giving tuberculosis drugs to an IGM patient by mistake is both unnecessary and causes the underlying disease to progress. Although there may be some clues on examination and history, definitive diagnosis is always pathological.

• Pain is more severe in IGM.
• Axillary lymph node swelling is more common in BT (50% versus 20%).
• BT patients may have a history of pulmonary tuberculosis.
• IGM patients are generally younger.

Which imaging methods are used in the diagnostic process?

Imaging methods are used to assess the extent of the disease and to guide biopsy. The biggest challenge here is that the findings almost always resemble cancer.

• Mammography
• Ultrasound (US)
• Breast MRI (MRI)

Ultrasound is the method we use most in diagnosis and follow-up. It usually shows an irregularly bordered, dark (hypoechoic) mass-like area. It also plays a critical role in detecting abscess formation and guiding drainage of that abscess. Breast MRI, on the other hand, is requested especially to understand the full extent of the disease and to identify other foci that may be hidden on mammography and ultrasound.

The fact that imaging findings overlap so much with cancer often causes radiology reports to be rated as BI-RADS 4 (Suspicious) or BI-RADS 5 (Highly Suspicious for Cancer). This scoring means “urgent action (biopsy) is required until cancer is excluded.”

Which biopsy technique is preferred when granulomatous mastitis is suspected?

In a suspicious mass, the current approach for tissue diagnosis is an “image-guided” (usually ultrasound-guided) Core Needle Biopsy (CNB), also known as “Tru-Cut Biopsy.”

Fine needle aspiration (FNAB) is not sufficient for this disease because it only retrieves scattered cells. We need to see the “tissue architecture,” meaning how those inflammatory cells (granulomas) cluster around the milk glands (lobules). Core needle biopsy allows us to obtain enough tissue to evaluate this architecture.

The tissue sample should be sent to two separate laboratories.

• Pathology (to distinguish Cancer, IGM, BT)
• Microbiology (for cultures for Tuberculosis, Fungi, and Corynebacterium)

Why is granulomatous mastitis treatment so difficult?

The main difficulty in treatment stems from the chronic and recurrent nature of the disease. The course of the disease varies greatly from person to person, and there is not yet a single universally accepted treatment guideline. Treatment decisions require establishing a critical balance between two main goals: controlling the disease and minimizing cosmetic damage to the breast (scars, indentations). Recurrence rates have been reported to be as high as 50% in some series.

How is treatment decided and what is the Turkish Clinical Classification (IGM-TCC)?

To provide a more structured approach to this variable disease, severity-based algorithms such as the IGM-Turkey Clinical Classification (IGM-TCC), pioneered by experts in Turkey, have been developed. This classification developed by experts in Turkey provides a roadmap based on disease severity.

• Type 1 (Mild Disease)
• Type 2 (Moderate Severity)
• Type 3 (Severe Disease)

This classification guides the general surgeon toward the most appropriate first-line treatment according to the current state (severity) of the disease.

How is mild (Type 1) granulomatous mastitis treated?

If the disease is Type 1 (i.e., the mass is small and symptoms are very mild or absent), the most widely agreed first-line approach is Watchful Waiting.

This approach is based on the fact that granulomatous mastitis can sometimes be a self-limiting disease. In some patients, it can completely resolve on its own within 2 to 24 months without any treatment. The main goal in these mild cases is to avoid exposing the patient to unnecessary cortisone burden or surgical scars.

What is the first treatment option for severe (Type 3) granulomatous mastitis?

If the disease is Type 3 (i.e., widespread, painful, abscess-forming, and aggressive enough to significantly impair quality of life), the most widely agreed first-line treatment is Systemic Corticosteroid (SS) therapy. Cortisone strongly suppresses this excessive immune response from within.

If the patient has a condition that prevents the use of cortisone (for example uncontrolled diabetes, hypertension), then Immunosuppressive Therapy (IMT), i.e., other medications that suppress the immune system (such as Methotrexate), is recommended as the first option. During pregnancy or breastfeeding, observation is generally preferred.

How is it decided that treatment is complete and what does “CCR” mean?

This is perhaps the most critical point of this treatment. One of the main reasons the disease used to recur so frequently in the past was stopping treatment too early. According to current consensus, treatment should be stopped only when “Complete Clinical and Radiological Remission” (CCR) has been achieved.

CCR means being sure that the disease has completely ended and has two components:

• Clinical improvement
• Radiological improvement

Stopping treatment by relying only on the disappearance of symptoms (clinical improvement) is not sufficient. It is also necessary to objectively confirm on ultrasound or MRI that the inflammation (abscess, edema) has completely resolved (radiological improvement). “Subclinical” (asymptomatic) inflammatory foci left inside will cause the disease to flare up rapidly once treatment is discontinued.

What is the role of surgery in granulomatous mastitis treatment?

The role of surgery in granulomatous mastitis treatment has changed and decreased over time. Surgery is now generally reserved for limited situations where it supports medical therapy or where medical therapy fails. Surgery is now a tool used only in specific and mandatory situations.

• Diagnostic uncertainty (if biopsy is insufficient)
• Abscess and fistula management
• Persistent masses not responding to medical therapy (cortisone/IMT)

What is the best approach if an abscess develops?

When the disease presents with an abscess, the modern approach is to prefer minimally invasive techniques (those causing the least tissue damage). The previously common “Incision and Drainage” (I&D), meaning opening and draining the abscess with a large incision, caused significant indentations and permanent scars in the breast.

Today, instead, Ultrasound-Guided Percutaneous Drainage is strongly recommended. In this method, the location of the abscess is identified with ultrasound and the abscess is drained through the skin using a thick needle or a thin catheter. This speeds healing and preserves the aesthetic appearance of the breast.

Is wide excision of the breast mass (WLE) a good solution?

“Wide Local Excision” (WLE), i.e., surgically removing the inflamed tissue along with some surrounding healthy tissue, is one of the most controversial topics in treatment. The biggest disadvantage of this surgery is the serious cosmetic problems it causes in the breast (large tissue loss, deformities, asymmetry).

In addition, since the disease is often diffuse in the breast, surgical margins may not always be clear, which can lead to recurrence despite surgery. Therefore, today WLE has ceased to be a primary treatment for the disease itself and has become an option reserved only for localized, stubborn cases resistant to medical therapy.

If surgery is mandatory, can the breast shape be preserved?

Yes. If WLE (wide excision) becomes unavoidable, the surgeon needs to obtain wide margins to avoid leaving inflamed tissue behind. This creates a risk of significant volume loss and deformity in the breast.

At this point, Oncoplastic Breast Surgery (OBS) techniques are integrated into the surgical strategy. These techniques aim to reshape the breast while removing diseased tissue.

• Therapeutic mammoplasty (with breast reduction techniques)
• Local tissue rearrangement (flaps)
• Achieving symmetry with the opposite breast

This approach aims to maintain disease control while also protecting patients’ quality of life and psychological well-being.

What are the risks and success rate of cortisone therapy?

Systemic corticosteroids are the accepted first-line medical treatment for severe (Type 3) IGM and can provide complete response rates of up to 80%. However, this effectiveness comes at a cost. After treatment is discontinued, a relapse (recurrence) rate of approximately 20% has been reported.

In addition, the treatment duration is usually long. Long-term cortisone use carries risks that must be carefully managed, especially in patients with comorbidities.

• Increased blood sugar (Diabetes)
• Increased blood pressure
• Weight gain
• Stomach problems
• Risk of osteoporosis

What treatments are used if the disease recurs?

If the disease does not respond to initial therapy (for example cortisone) (refractory) or recurs after improvement (relapse), treatment is escalated to the next step. At this stage, Immunosuppressive Therapy (IMT), i.e., immune-suppressing medications (such as Methotrexate), comes into play.

In these difficult, resistant cases, combination therapies are often required.

• Methotrexate + Low-dose cortisone
• Surgery (WLE) + Cortisone

Do antibiotics have a role in granulomatous mastitis treatment?

In general, because idiopathic granulomatous mastitis is not an infectious disease, antibiotics are ineffective. Antibiotics are useful only in two specific situations.

• CNGM subtype
• Secondary infection

If the diagnosis of Corynebacterium-associated CNGM is confirmed on biopsy, long-term antibiotic therapy is required. Or antibiotics may be used if an existing abscess becomes secondarily infected.

Frequently Asked Questions

Which factors are considered in granulomatous mastitis treatment?

A personalized treatment plan is created by evaluating the patient’s age, disease severity, extent of the lesion, and previously applied treatments.

Does granulomatous mastitis have a different course during pregnancy or breastfeeding?

Although the disease is not directly related to breastfeeding, closer monitoring is required during pregnancy or breastfeeding. Treatment is planned with the safety of the mother and baby in mind.

What are the differences between granulomatous mastitis and infection?

Granulomatous mastitis is not infection-based; it is an inflammatory disease. While infections are treated with antibiotics, immune-modulating drugs are generally preferred in granulomatous mastitis.

When is surgery necessary in granulomatous mastitis treatment?

Surgical intervention may be considered in cases that do not respond to medical therapy, show abscess formation, or form a prominent mass. Minimally invasive methods are generally preferred.

Which complications may develop in patients with granulomatous mastitis?

Abscess, skin retraction, chronic wounds, and rarely fistula may develop. A prolonged treatment process can also be psychologically challenging.

What is the risk of recurrence after granulomatous mastitis treatment?

The risk of relapse is high. Regular follow-up, adherence to treatment, and management of underlying causes can reduce the likelihood of recurrence.

How is quality of life affected in patients with granulomatous mastitis?

Pain, aesthetic concerns, and a long treatment period may reduce quality of life. Psychological support and proper information help the patient manage the process better.

Which lifestyle changes are recommended for granulomatous mastitis?

Stress management, balanced and healthy nutrition, and habits that support the immune system contribute to the treatment process.

Is there a relationship between granulomatous mastitis and breast cancer?

Granulomatous mastitis does not directly cause breast cancer, but because it may be clinically confused with cancer, biopsy and close follow-up are important in diagnosis.

Will there be deformity in the breast after granulomatous mastitis treatment?

Indentation, tissue loss, or deformity may occur due to inflammation and surgery. If necessary, correction can be performed with aesthetic surgery.

How Long Does Granulomatous Mastitis Treatment Take?

The duration of granulomatous mastitis treatment may vary depending on the severity of the disease, response to treatment, and the treatment method applied. Generally, treatment may take from a few months up to one year.

Which Doctor or Department Should You Visit for Granulomatous Mastitis?

To evaluate the condition and initiate the treatment process, you should first consult a general surgery specialist, especially a physician experienced in breast surgery.

How is granulomatous mastitis treated?

Granulomatous mastitis treatment is planned according to the extent and severity of the disease. The most commonly used method is cortisone therapy. In some patients, antibiotics or immune-modulating medications may be preferred. Surgical intervention may be required in resistant or recurrent cases. The treatment process generally requires regular follow-up.

How is the Prednol dose determined in granulomatous mastitis treatment?

The Prednol (corticosteroid) dose is determined by the physician according to the patient’s clinical condition. It is usually started at a low or moderate dose and gradually tapered based on the response of the disease. The dose and duration of treatment are individualized; uncontrolled use without a doctor’s recommendation is definitely not recommended.

What happens if granulomatous mastitis is not treated?

If left untreated, painful breast masses, draining fistulas, and skin breakdown may develop. The disease may become chronic, leading to recurrent abscesses and deformity of breast tissue. Therefore, early diagnosis and regular follow-up are important.

Is granulomatous mastitis cancer?

Granulomatous mastitis is not cancer. It is a benign inflammatory breast disease. However, because clinical examination and imaging findings may resemble breast cancer, definitive diagnosis is made by biopsy.

Can granulomatous mastitis turn into cancer?

Granulomatous mastitis has no risk of turning into cancer. However, if it is not controlled for a long time, tissue damage in the breast may increase and imaging findings may be confused with cancer. Therefore, regular physician follow-up is important.

What is the course of cortisone therapy in granulomatous mastitis?

Cortisone therapy suppresses the inflammatory process, leading to regression of the mass and pain. Treatment may generally last for several months and the dose is reduced over time. The patient is monitored at regular intervals for possible side effects.

What are the symptoms of granulomatous mastitis?

The most common symptoms are a painful and firm breast mass, redness, swelling, and increased warmth. In some patients, discharge, skin breakdown, and recurrent abscesses may develop. Symptoms most commonly occur in one breast.