[Music] [Music] [Music] he [Music] [Music] [Music] [Music] [Music] over to you sir we are live yeah uh good evening to all of you and welcome to this am I audible yes sir yes sir and welcome to this 31st seminar uh though the name of the seminar is focus studies in breast cancer uh which we are conducting for the last 3 years uh virtually every 4 to 8 weeks this time the topic that after long uh discussions we chose a topic uh which sometimes on presentation May mimic inflammatory disease sometimes may mimic cancer but which is Diagnostic and treatment difficult situation what we call as idiopathic gomitas mesitis and we were all surprised to see that the number of registrations this time has far exceeded than any other the seminar before uh with these few words I welcome to the panelist and welcome to all the delegates because of them this seminar for the last three years is a is a very successful seminar because of the hard work done by some of our younger colleagues uh particularly I always mention the name of Dr Vali uh Dr safala Dr PRI and Dr Jan these are the young people who are backbones of this seminar they do lot of hard work along with my ideas to make this uh seminar success so welcome once again and hand over to uh the convener so today um I am actually going to be talking uh on the clinical spectrum of idopathic granulomas mesitis and as well as we going to have a wonderful panel discussion on the same topic uh some of the panelists have already joined so uh without wasting any further time I would actually uh like to start I hope my slides are visible yes ma'am it isible yeah so um once again a very warm welcome to all of you and um as uh Dr Rajiv already mentioned that this is a topic which we have actually uh selected with lot of deliberation because it's it's a very important uh topic uh and it is it's it creat a lot of uh you know confusion in our minds regarding uh the diagnosis as well as the treatment of this condition and why it is important for all of us is because of the fact that it closely mimics malignancy and we are always worried when the patient comes to us with uh uh similar situation as to whether we are really missing out on any uh you know Sinister pathology here or not so my presentation is going to uh involve the clinical presentation diagnostic workup what are the diagnostic difficulties and what are the therapeutic options guidelines I do did mention here but there are no uh you know specific guidelines uh as to how to manage this disease so this uh condition this challenging clinical condition was first described in 1972 by Kesler and warock it's relatively uncommon but it's it's very difficult as I mentioned earlier that it's very difficult to differentiate it clinically as well as radiologically from malignancy and because uh you know because there are there's a lack of consensus regarding the ethology pathophysiology and management options that we have chosen this topic for discussing today this was initially actually used to be misdiagnosed clinically as breast carinoma and uh you know in the paper published in 1972 by Kesler and w they have mentioned that uh you know all those five cases which they have described in the in this paper they were referred to them uh as malignancies and those patients were uh treated with mastectomy it was later that the mastectomy specimens were actually analyzed histopathologically and they were found that this is not uh malignancy but this is something uh distinct and then uh these two uh you know surgeon scientists have labeled this as granulomatous mtis so it was earlier misdiagnosed as breast carcinoma then they used to be confused with plasma cell mtis fat necrosis and of course tubercular mtis was very common at that time so it is also called as granulomas lobular mtis it's a benign inflammatory condition of the breast uh with a pathognomonic feature of epitheloid and multinucleated giant cell granulomas which are limited to the mammory lobules so that is how it is actually distinguished from uh you know other tubercular mtis and all micro absis formation without any obvious eological factor is uh another important feature which is seen in uh you know the pathological specimens of granulomas mesitis so when we talk about granulomas mesitis uh it is divided into two distinct uh you know subgroups that is one is primary or ideopathic gratus mesitis where we are not aware or we are not sure about what is the eological agent and then there are specific granulomas mesitis like which are associated with other autoimmune dis disorders or tuberculosis or fungal infections so the eological factors which are actually proposed are either as a result of autoimmune uh you know reaction to some unknown agent or as a direct impact of trauma it is also considered to be a metabolic disorder or it is related to hormonal imbalance and occasionally an infective agent like or bacterium is also implicated in the eological factor however none of them them has actually been proved to be uh you know directly leading to the uh development of granulatus mesitis then there are other potential precipitating factors which have been proposed in different uh you know Publications the important being association with pregnancy and lactation and other conditions which lead to hyperprolactinemia use of contraceptive pills truma foreign body reaction smoking alpha 1 antirion deficiency and other autoimmune it is also found to be associated with other autoimmune disorders however most women with uh presenting with IGM do not show any systemic immune abnormalities the pathophysiology which has been proposed uh is the major component is related to milk stasis and that is the reason it is actually seen commonly in association with or in younger women who have recently uh you know delivered and uh under undergone I mean have breastfeed their children so it is proposed that the repeated microt trauma during breastfeeding in addition to the stasis of milk in the milk ducts leads to triggering of an autoimmune process because of the milk proteins and this process is actually supplemented by an infective agent called Corin bacterium species that leads to damage to the ductal epithelial lining and as a result the ductal contents actually influx or uh invade into the adjoining lobular tissue which leads to local inflammatory response in the lobules and as a result of this inflammatory response there is migration of neutrophils and macras and other uh you know imuno modulatory uh cells and as a result it leads to non-cas granuloma formation and if the process is allowed to continue without any treatment then there are micro abesses which are formed these microabscesses can coals to form a bigger absis so this is a general pathophysiology of this uh condition which is proposed this is the same thing uh when we talk about clinical presentation as we mentioned earlier it is seen in young women of childbearing age mostly seen in the postpartum phase or occasionally during breastfeeding you know stages of the uh women's life it is commonest in third and fourth decade rarely very rarely seen in women older than 50 it is common in nonwhite women Asians Hispanics and Middle Eastern women there are few case reports where males have also been found to have suffered from granulatus mesitis and there are some reports where transgenders have also been found to have granulatus mesitis we do not know the exact prevalence of the disease but one of the papers which was uh published from Washington USA has mentioned that the incidence is nearly around 2.7 per 100,000 uh you know population however because it is a non-notifiable disease the exact incidence and prevalence is not known no association has been found to be uh between uh the granas must is and future can cancer risk it is rarely seen in niip Paras women however hormonal imbalance or hyperestrogenemia is also considered to be one of the potentiating factors the commonest clinical presentations include palpable tender Mass occasionally it can be seen in bilateral and on both the sides and IL defined enduration with areas of softening is a common clinical finding some times patients do present with nipple discharge uh if the you know the disease process is extensive then nipple discharge also can be seen then Regional or focal arida can also be found and these areas of abnormality are tender to touch skin edema you uh you know presence of pdod all these things actually these uh definitely lead to confusion clinical confusion and we always worry about whether we are dealing with caner here or not then if the disease process is allowed to progress if the patient develops recurrent disease then discharging sinuses are another important clinical finding which we come across we do see axillary lymphadenopathy in nearly 30% of the cases but most of them are found to be reactive lymphadenitis so these are some of the clinical pictures which have been taken from internet as well as some from my own clinical practice the these are the presentations which I have already mentioned so when we come across such a situation clinically we tend to suspect either we are dealing with granulomas pathologies it could be bacterial absis could be tubercular absis could be fungal problem could be foreign body reaction fat necrosis or it could be lactational mtis if the patient is in that age group and definitely we have to find out whether it is malignancy or not tubercular statis is an important actually differential when it comes to situation in India so how do we proceed we have to focus on clinical history especially patients childbearing history patients lactational history any drug related uh you know uh presentation especially patients have been found to have hyper Prolia if the patient is on anti-depressant so we have to take that history carefully we have to find out what has been the progression of the disease disase whether the you know patient has started with inflammatory signs and symptoms all of this is very very critical before we proceed and with clinical history taking as well as examination we come across a situation where we can generally suspect that probably we are not dealing with malignancy but it could be a condition called as granulomatous mestis however appropriate breast Imaging and tissue diagnosis very important to cool out malignancy and other causes of the presenting condition tissue diagnosis is considered to be the gold standard for diagnosis so the role of serum prolactine and serological Markus is actually highly debated whether it has any therapeutic implications we do not know Imaging x-ray chest is advised to rule out presence of tubercular uh you know chest infections ultrasound scan is considered generally to be the first uh Imaging modality of choice then we can definitely make use of bilateral digital mamography as well as occasionally MRI breast to uh you know come to uh uh to collaborate with our clinical findings as I mentioned tissue diagnosis is most critical to come to the diagnosis in addition to that gr stain AFB stain P stain and other stains are critical to rule out other causes of granulomas mtis culture and sensitivity although it has been mentioned but we find that majority of the cases the cultures come out to be sterile Gene expert rtpcr for tuberculosis is also recommended especially in our situation when we occasionally come across tubercular mestis as well then there are tests which are definitely needed to rule out sasis also so when we talk about Imaging there are no pathognomonic features either on ultrasound or mamography or MRI which which will definitely tell us that yes we are dealing with granulomas mtis and nothing else however Imaging provides supportive evidence for diagnosis and it also helps in documenting number size and location of the lesion so as to take a decision about what should be the treatment modality which can be offered to the patient Imaging definitely helps in performing biopsies guided aspirations making intal lesional injections monitoring response and detecting new lesions so ultrasound scan features usually are non-specific they can mimic cancer in the form of either skin or travic thickening edema lymphadenopathy usually the case presents like a lobulated errogenous hypo Mas eoic mass or there can be more number of masses with irregular and angular margins and some of these features definitely uh you know uh confuses us whether this is cancer or not the then there are fluid Collections and absis formation and sinus tracts also can be seen mamography again as I mentioned there are no specific mammographic features of this condition usually patients present with unilateral focal or Regional asymmetry with or without Associated architectural Distortion occasionally this condition can be mammographically occult because patients are usually young um then breast MRI it is useful when mamography and ultrasound are not conclusive and the features which are seen on breast MRI include heterogenously enhancing or re enhancing masses which may show Progressive or Plateau type of kinetic cures uh P2 hyperintense enhancing Mass with or without non-mass like enhancement is considered to be uh an important feature found on breast MRI then there are the margins and shapes of the masses can be you know variable they can be circumscribed round oval or irregular uh uh MRI also helps to characterize nipple retraction sinus tracks and parimal Distortion tissue diagnosis is the next step and this is uh the most important step for diagnosis generally cor nle biopsy is what we should be advising because it has got a very high sensitivity incisional or excisional biopsies may be needed if cornal biopsy does not give us the answer which we are looking for fnc is now actually not considered to be uh you know uh the pathological modality of choice because it has got a very low s sensitivity the commonest histopathological or pathognomonic features of this condition are lobulos Centric granulomas which are non-tic they are seen in almost 100% of the patients and addition of langin type of giant cells is also very commonly seen with micro absis formation necrosis and and neutrophilic eosinophilic infiltrates interlobular inflammation fat necrosis and other changes can also be commonly seen But the most important or I would say uh commonest feature is lulus entry granuloma which is actually helpful in distinguishing this condition from other granulatus mestis these are some of the you know pathological uh features which we have mentioned then differential diagnosis actually uh by presence of noning Lilo entry granular Mas by presence of localized infiltration of multinucleated giant cells epitheloid histiocytes and other cells organized sterile microabscesses and very very rare involvement of ducts and sterile cultures these are some of the important features which help pathologically uh in differentiating idiopathic gratus mesitis from other other conditions uh which we have already discussed uh these are some of the important uh you know uh conditions which can closely mimic uh IGM and these need to be actually ruled out before we come to the confirmatory diagnosis so these are some of the uh you know workup modalities which help us to differentiate whether we are dealing with some other autoimmune condition or not so when it comes to the most important aspect of this condition that is the management of uh idiopathic granulatus mestis there is a l hell lot of confusion as to what should be the initial modality what whether it we we should treat with surgery whether we should treat with steroids how long there is no absolute consensus about this treatment it is usually considered to be self-limiting but it has got a long and protracted course usually to the tune of s maybe few years and but at the same time a lot of anxiety related to the symptoms symptom burden recurrent disease all of these actually impacts the quality of life of the patient and as a result the treatment is very important there is no consensus as I mentioned on what is the optimal treatment however a multimodality approach to the treatment including the medication surgery repeated aspir these are the ways the patients are usually treated observation antibiotic steroids other immunosuppressant and surgery these are the main stay of treatment uh of this condition observation uh as I said uh the literature says that nearly 50% of the early uh presentations resolve spontaneously in these patients who have very limited or early disease we can choose to observe this patient of course with close followup um but that should be done only after confirmation of diagnosis by means of corle biopsy and however these patients may need some symptomatic treatment some analgesics in addition to the reassurance this is what has been actually proposed by uh Professor Benson in this uh you know article which is published in uh 2021 then is there any role of antibiotics this is actually a highly debated uh you know question which is considered a very critical thing when we talk about granatus mtis it as many of these Publications have proposed that corinium uh species is commonly associated with this condition and as a result many of these uh you know case series or individual Publications have proposed prolonged use of lipop IC antibiotics like Clarithromycin or doxycycline or Augmentin that is amoxyclav lentic acid for prolonged periods like 7 to 8 months and in addition to this it is very important to monitor the response if the patient shows any signs of improvement then the authors have proposed that we should actually continue these antibiotics till cont complete resolution which can usually take 8 to 9 months and why but at the same time we have seen that the cultures many of times come out to be sterile why the possible causes which are actually proposed for sterile cultures is that patients usually are actually uh you know presenting with previous use of antibiotics and as a result the cultures usually come out tester these bacteria are very slow growing and they have fastidious growth requirements we generally do not use those cultures which are needed for the specific growth of these bacteria and usually these are uh the growth if at all it uh you know is shown on the cultures it is usually dismissed as contaminants and sometimes the sampling which is sent to the microbiology lab is also inappropriate as a result many of the times even if we order cultures the cultures come out to be sterile so it is very debated whether these antibiotics do they have any role or not however some of the papers have definitely mentioned that long-term use of antibiotics may be important for management of this disease then steroids steroids are the main stay in the treatment of management of granulatus mtis the first use of steroids was proposed in 1980 for the first time and it is actually critical to use these uh you know uh medication in moderate to severe presentation however it is important to confirm the diagnosis uh and to rule out any bacterial infection before we start with steroids and the patient should not have any contraindication to the steroid therapy oral oral steroids topical and intralesional steroids are the various Ways by which steroids are administered the important goal of steroid Administration earlier was minimal effective dose for short duration however it was found that premature tapering of steroids leads to uh immediate rebound of the condition and as a result the uh you know the papers have mentioned that oral predis alone should be started with the dose of 30 to 40 milligram per day for over 3 to 6 months and if the patient is a you know able to tolerate then the dose can be increased to 60 milligram per day if the patient is tolerates and the patient shows any good clinical response the proposed schedule for oral steroids is 30 to 40 migr per day till we start seeing the response that might usually take 4 to 6 weeks and gradually the tapering of the dose can be done to 20 milligram per day over 2 to four weeks gradually and once the tapering uh is done to 20 mgram per day we can actually continue that for 3 to 6 months and very very gradually reduce Maybe by 5 mgram uh you know at one time for three to 6 months and then if the patient shows complete response it can be discontinued topical steroids are also found to be effective in the treatment of ideopathic granulomas mtis uh steroid pomet creams ointments are proposed for the use pris alone 0.125% or triin alone .1% twice a day on Alternate days for 4 days a week uh for 6 to 8 weeks has been proposed these type of treat know modality of treatment has been found to have less side effects compared to the oral uh uh steroid preparations and they have been found to have good resolution of fuli and sinuses in addition to the topical steroids combined intralesional steroid and topical steroid Administration has been found to be more efficacious so intal triamcinolone actinoid injection uh in the dose of 20 m per cubic cm in the center of the Legion once a month under Imaging guidance in addition tronolone acoid acetonide topical uh Administration uh is recommended for this kind of treatment a repeat ultrasound scan should be done every month and repeat injections uh should be done monthly uh till the resolution is complete and usually three to four such injections are required that is what the paper suggest if the patient has got an extensive and diffus disease then multiple sites of injections can be done and uh if there are multiple Legions then each Legion can be individually injected separately the uh in intal injections have been found to have equivalent efficacy and less systemic side effects however the exact duration of treatment how long does it take for the entire uh you know disease to resolve completely is actually not known uh and it has also been mentioned that sustained response may or may not be observed so it is very you know difficult to understand whether we can continue only with injectable or intralesional steroids or oral steroids also need to be supplemented so when we talk about steroid treatment there are obviously side effects of prolonged treat therapy like mood changes weight gain elevated blood pressure sugar intolerance and all of that so that is the reason actually patients are very reluctant to continue use of steroid for a long duration some non-steroidal immunosuppressant have also been proposed mythri set in the dose of 10 to 15 milligram weekly for a duration of 3 to 6 months and with slow tapering the symptom resolution rates are approximately 83% however there are recurrences as well to the tuna 70 to 20% and similar actually uh you know uh rebound phenomenas are seen with oral steroids as well other uh imuno supressant which have been utilized are aprin molate mtil and all that but however the experience is limited surgery yes it is important and all of us uh you know are usually the surgeons are usually the people who deal with granulomas mtis it was the only treatment which is proposed for this condition till 198 is uh it was actually found that surgery although it may be done with good margins but it does not prevent recurrences so the recurrences which have been you know uh found in publish literature are uh reported to the tune of 5 to 55% it is actually limited to those patients who are non-responders to steroid treatment or those who have severe symptoms absess formation or fistul formation and these patients may need multiple surgeries to achieve remission and when we talk about excision of large masses definitely that leads to inevitable cosmetic outcome and unsightly scars mastectomy with breast reconstruction has also been performed for some patients however this leads to huge psychological and financial impact and is not a routinely recommended procedure when we talk about surgery for early disease it is called it is considered ideal for localized uncomplicated very small Legions when you are able to excise a legion with a good margin of healthy tissue and there is no sign of skin involvement or impending fistular formation when the disease can be excised with a clear margin so that the patient does not need any subsequent uent oral steroids the other modalities of interventions can be repeated ultrasound guided aspirations if the patient develops P formation in ingen drainage or surgical debrine B may may be required white local exgen I already mentioned partial mastectomy with volume replacement can also be performed mastectomy very very very rarely with you know for patients who have intractable disease and patients may need surgical intervention for percutaneous drainage with or without pulara track removal it is proposed that the you know excised uh raw area should be left for secondary healing and later on maybe delayed fat grafting or autologous flap may be used for replacing the Lost volume this is uh you know the uh I have taken this from this paper the authors have actually showcased one case where a wide excision of the uh involved part of the breast was done and it was replaced with latius dorsa flab so this is the management algorithm uh when the trut biopsy shows that it is granulatus mtis if it is a localized small lesion then you can observe either observe or if the patient needs or wishes for surgery then surgical exision with negative margins if it is going to preserve the Cosmetic outcome if it resolves good well and good if the there is recurrence then you can start with steroid or votrix therapy for borderline lesions depending on the patient preference whether to start with medical treatment or surgical oygen definitely needs to be counselled uh after the uh good counseling session for large and diffuse complicated lesions definitely start with oral steroids or intal lesional steroids if the legions resolve fine and observe and if the there is failure of the treatment then surgery is the ultimate modality of option for this patient uh there have been uh some papers and especially this paper which is published the metaanalysis of comparison of conservation versus surgical management protocol for this condition it is be found that found that there is no significant difference in the recurrence rates of IGM after surgical or medical or conservative approaches multiple surgeries have been found to lead to higher probability of wound infection s sinus formation and definitely cosmetic deformities hence the pharmaceutical approach with or without surgery is strongly recommended as the first modality of treatment surgery is recommended for recurrent patients or patients who have lack of response to uh pharmaceutical treatment so uh to conclude before I conclude I would say that idopathic granulomas mtis is a rapidly Progressive inflammatory condition the clinical and imaging features actually troubless they mimic breast carcinoma the other important troubling part is that there is lack of consensus on what is the optimal management of the disease there are recurrent episodes and patients definitely are symptomatic leads to lot of scarring breast deformity and patient and the family members are always anxious about this condition so this treatment actually this condition needs to be treated as a teamwork we have to go hand inhand with our pathology and Radiology colleague and of course the patient and her loved ones have to be reassured counseled at multiple times so that the patients uh you know don't lose hope in the treatment and that is how uh I'm going to conclude my talk and uh we'll move ahead uh thank you Dr bashali uh for a wonderful talk for a disease Which is less to and less well managed so it's time for the panel discussion uh actually I was supposed to moderate this uh panel discussion but my throat is bad so I have requested my colleague Vali only to continue with this uh as a moderator to this panel discussion uh we have a very very learned panel today uh just to introduce in short uh Dr Gita [Music] dep Dr is from all Institute of Medical Sciences Bal drti is a colleague at medanta a dedicated bestest radiologist now in the town for almost 14 15 years and Dr Kavita is a pathologist at Mex super Specialty Hospital shal marbal over to sh please for conducting the uh session thank you sir uh let me just yeah um is the slide visible are my no okay just a moment just a moment give me a minute no this is not the one I think Dr Vali we could maybe start some of the discussion just a moment just a moment I hope now is it visible yes so uh welcome to all my panelists Dr Rajiv has already welcomed them so I'm just quickly going to show you one case and then uh we will actually move on with the discussion so this lady came uh in October to me she's a 34 year old premenopausal mother of two uh having uh you know delivered her last child 5 years ago she presented with a lump in breast left breast progressively increasing in size for last four months and recently she noticed nipple detraction she also had some mild tolerable pain in left breast no fever and no other significant past and family history this is how she presented with uh you know left breast uh bigger looking than the right one and a large palpable IL defined lump in the parer quadrant so the uh uh before actually I'll proceed with the other findings I would actually like to ask uh um you know all my panelists especially the surgeons uh Dr Gita Dr swagata Dr Anan uh and Dr anupma um one by one maybe how fre quently do you see uh you know patients with granulatus mesitis uh Dr Gita so you know it is variable they come in crops sometimes in a month you'll be seeing about three of them and essentially in a year I would say we close to 15 to 20 cases of granus mystis I would think in a year in a yeah and Dr anopa I would say it's more than that like every day I'm seeing about at least two three but many of them are followups so new cases would be maybe five to 10 in a month okay that's that's quite a you know large High number that's a high number a high number that's a high number yes H Dr swagata and Dr Anand both represent you know public sector large hospitals so uh is the number higher in your centers or similar it is more or less similar similar okay and how what are the common presentations with which you come across such patients is it a mass or what what tender mass and sinuses and discharging sinuses discharging sinuses uh Dr Gita so sometimes you know you may not have a tender lump it is just a lump it's a large lump and you almost think that oh God this young woman has got a cancer but you know it is an IL defined it is large it is of recent origin um say a month and you and it's kind of rapidly grown to that size but you know it's not a fos because it doesn't feel like a pho it is just an a lump with il defined margins um and sometimes I've had patients who've come simultaneously with joint pains also so you have somebody complaining of ankle pain somebody having elbow shoulder uh and all of this has happened kind of simultaneously sometimes the joint pains may precede the occurrence of the lump okay so uh Dr anupma like Dr Gita has mentioned um what are those features which sinuses and all of those that is that is a different thing but otherwise you know you do get to see yeah so um I was asking uh Dr anupma what are those clinical findings or you know clinical features which probably allow you to think that probably you are not dealing with cancer here but it could be granas mes is there anything else which you would uh you know add to what Dr Gita has already mentioned so basically uh softening of the lump or you know clearcut abscesses clinically you can make out its an absis so that would definitely tell you that it's unlikely to be a malignancy and more likely to be um granular Mattis right so um now when you come across such a situation what is your you know first modality uh of um investigation uh I would say uh how do you proceed um first would be ultrasound first would be ultrasound yeah and that'll give us a very fair idea because I think ultrasound is quite good in uh detecting this kind of Il defined diffused mesitis the sinus tracks and the collections multiple abscesses all over that gives us a fair idea that we are dealing with this right uh Dr JY U do you agree with this uh and what will you prefer to evaluate this patient uh as a first modality of treatment yeah she's 34 and um so my first line of my first choice would be ultrasound and as you said like clinically also it's pointing more towards inflammation so uh there is no reason to start with mammo we would start with an ultrasound first and usually in such cases what we see would be an irregular hypo areas which have those branching patterns or tentacles then there would be streaks of fluid skin thickening a lot of Edema and uh the T tentacles or the branching tubular areas of breakdown that we see is because they're insun in or you know um going around the fat lobules that's why we see them they are not penetrating into the um into the fat lobules so that those kind of appearances uh you know give us a very good hint that this is more likely to be an inflammatory lesion rather than uh cancer but saying this when they come in the very very initial phase when the the areas of breakdown have not yet started once the areas of breakdown are there then you know internally we see mobile Echo it's much more easier to tell us but in the very very initial stage when it's all like an inflammatory soft tissue going along the ducts we do get confused with the uh you know the non-mass findings that we see on ultrasound which are you know very um indicative of dcis or you know dctal iology Sinister iology and then when it is you know at that that stage very early stage where it's very difficult and even on the Mr you know they show us the typical segmental non-mass enhancement with clustered ring appearances and no uh absis formation yet so uh these are the areas uh these are the times when uh we also do get confused that is it really malignancy because there are no areas of breakdown no discharging sinuses no tracking along the fat globules reaching up to the skin so that is the time when I would definitely go for an MR provided sorry go for a mammo first provided the patient is not uh you know in lot of pain and at times if it is DCs I've seen a lot of time there would be some micro calcification which really helps me to make my uh you know uh decision whether this is inflammation or this is just uh or is it like a malignant itology the other thing is most of the times when you have those segmental invol areas of involvement uh the the discharge here would be pass or milky discharge that would be coming or uh but if it is dcis or a malignant itology if we are dealing with bloody nipple discharge then although the appearances on ultrasound might be similar I would be thinking more in terms of malignancy then so clinical information help us micro calcification help us and if we can see areas of breakdown that's the time when we are much more confidence saying this is more likely to be an inflammatory theology rather than um right rather than malignant so I think uh we all would agree here that uh many of times we need to you know involve Ultra the help of ultrasound mamography as well as MRI you know uh get as much information as is actually uh possible uh especially in such young women like we previously mentioned that mamography uh may not be a first modality of choice here because one is because the women are young the other is because uh you know the there's lot of discomfort as well but sometimes as Dr ji has mentioned you know the presence of micro calcification can also help us to decide whether this is uh dcis we are dealing with or it's you know something else so this lady has undergone um ultrasound elsewhere I don't don't have the you know images which was reported as diffuse fibr glandular paranal tissue with increased echogenicity and an IL defined irregular hypo lesion in the upper inner quadrant and it was labeled as query fibroadenosis so the uh the you know person who was initially treating her also advised her to go for a mamogram this was what uh it showed uh it showed an irregular IL defined area of density with architectural Distortion in the inner Central quadrant of the left breast uh Dr ji is there anything else which you would you know comment on this mamogram I mean the quality of the picture is not that great but is there anything else which uh basically I would really look for if I can see because um if you see it is more like a segmental and the Distortion that we are talking about it's actually all thicken ducts on the Ultras will be very uh you know it'll be much more clearer so they are coming in one segment and the ducts are thickened so I would really look for any micro calcifications now I don't think so but then obviously it's very hard without a MAG view so um yes I would um uh at this stage unless I see an ultrasound I would keep uh um both my malignant itology and an inflammatory lesion in um in my differentials because I'm not seeing any skin thickening uh there are no micro calcification but there is Distortion which is very uh you know a sign of sinister itology so I'll keep both of them in mind right so when she came to me this is what she came with an ultrasound and unilateral mamogram and the clinical you know picture was quite Sinister looking with lot of Edema and an IL defined lump and it was quite firm uh in the beginning so I also ordered an MRI uh these are the MRI uh pictures and the reporting was with minimal background enhancement and irregular Mass uh with clump non-mass like enhancement and all that and it was reported as Mr bides 5 obviously there were linear cluster dring and clumped nmle in the upper inner quadrant with skin thickening nipple detraction and wash out kinetics so with these findings definitely it was labeled as Mr pides five um then um since she had a clinically palpable node the FN of the node was also carried out it was reported as no evidence of malignancy no granuloma so uh obviously the next um I'm sure all the colleagues would agree that the next modality of uh you know investigation would be a core biopsy is there anything else uh Dr Gita uh you would like to do before we proceed with tissue diagnosis so you know if there is Frank absis or a Frank purulent discharge coming I would wait for the you know the uh the absis needs to be dealt with because you know at that time if you do a biopsy you may just end up getting some acute mastitis or something like that because that happens often but I've also had a patient who came to me with an eacy which said ductal carcinoma uh but you know when you when you look at it and you see that it is not uh you know so I I was almost convinced when I saw her because she had a small sinus uh just a little away from the mass and then we did a biopsy and that came back as chronic gr grantis atitis okay uh so so I think you know that that is the limitation I would certainly want a biopsy but sometimes I think granus mastitis is under reported right by yeah so you need an experienced pathologist also to be reporting with confidence on an IGM because a lot of times they just write granum as mesitis and leave it to you to figure out whether it is Cox or it is IGN but I can show yeah sorry sorry go ahead so what I can assure you what has happened is there has been a mind shift on our part also uh because earlier we were uh we would kind of be more happy uh trigger happy I would say and start off at you know uh but now in the last four or five years uh I have seen that I've been completely wrong on several occasions I think in the past but I can also say that you know akt also will work because this is long-term antibiotics you're giving for 6 months and you will get the response but we wrongly labeled a lot of patients as tubercular mastitis instead of IGM correct so it is very common to see that the patients you know come with somebody else starting uh you know having started on akt so at this stage if the patient has already been put on anti tubic treatment would you stop the treatment right away or would you what would you do uh in this situation if the patient comes to you like this and she's already being put on uh you know empirical anti-tubercular treatment uh would you one thing that is one one thing that has to be very very clear is that we should you know stay away from doing an empirical at there are a lot of medical legal implications also to it and we should be very very careful when to you know do an at without proof you you be kind of going to land in trouble right uh so that is one thing that we have to be very careful about but if somebody's already started MH you know the thing is we must understand if if the patient does not have tuberculosis and you're just putting her on akt and if she's IGM she's going to get worse on it because this patient possibly required antibiotics and required steroids and the imuno modulators and all of that but if it is not uh if it is actually tubercular and you want to do steroids it'll get worse again so you know we are caught in a catch 22 situation you do this you get get into trouble you do that you still get into trouble so you know so so it it is a conundrum I I I completely agree and it requires a lot of patience on the part of the treating uh surgeon as well as the patient yeah uh so coming on to Dr Anan uh do you also come across such a situation that the patient is already on anti-tubercular treatment or you uh you know you start anti-tubercular treatment in this situation is the what is your take on this so the first situation is very common am in patients are started in peripheral areas on tuberculosis drugs after these diagnosis of FN and then we don't start empirical anti we never use there has to be some evidence only then we will have anti patient will get anti and also this will be in consultation with our tuberculosis Department only right it's notified and notified disease and there are issues with the medical legal issues so yes most of time if there are any evidence we will have consultation correct um Dr swagata uh when a patient presents with uh you know significant inflammatory changes uh you know signs and symptoms and granulomas mtis uh do you start with some antibiotic and weight and then uh maybe go for uh biopsy what has been your uh practice so far see I start antibiotic and with the broad spectrum antibiotic generally with Augmentin and put the patient for the core cut biopsy wait for the report and if there's some discharge I go for culture which usually is comes at um nonsterile or contaminant of three bacteria because the the culture material is very small if it is so definit generally it comes as contaminant or sterile so I start with a Augmentin wait for the culture report and a tissue BFC if it comes granular and tuberculosis to be ruled out with CB nut tuberis is ruled out and a fungal culture generally I give all to my patients because in as we are having a fungal very excellent fungal culture department so uh after that if everything is negative I start continue with uh antibiotics for one month initially augmenting then with doxy then with classyin if patient is responding okay so uh Dr anatis diagnosis okay Dr anupma uh is it similar you do in your practice or something else no it is quite similar so basically I do an ultrasound ultrasound guided aspiration of the past sent it off for Gram stain AFB stain fungal stain uh aerobic cultures and take a core biopsy from the lesion or the wall of the absis and while all these reports are being done it takes about a week start her on antibiotics call her after a week and then reevaluate everything okay thanks so we'll uh now move to Dr Kavita the most important uh you know person in the uh you know diagnostic uh journey of this disease granulomas mesitis Dr Kavita uh so let us you know ask you about the the the the what are the clinches the pathological clinches which uh tell you that this is uh IGM and not nothing else so I'm going to show your slides but can you just elaborate on what all things you look for before you label it as uh you know granulatus mesitis yes ma'am so actually first of all this is a diagnosis of exclusion as all of us are aware that uh we have to undergo so many other tests so that we have to rule out other conditions and so that finally we come to this corre so of course as we have discussed elaborately uh I would give a gist that whenever a patient comes to you by for this diagnosis I think as ma'am had just mentioned Dr swagata that we have to take an aspirate for AFB culture yeah and then of course I think uh the TB pcrs generally we are uh I think the clinicians generally they say that the biopsy the block the uh block we can give for tbpcs but no I would say a fresh tissue in nor should be sent for tvpc so the complete work up would be the uh an aspirate for culture as well as for staining for a stain then uh fresh tissue in normal celline for TB PCR and then of course a biops but here I would just like to disagree ma'am that how does a core biopsy actually can we see the next slide so the pathognomic feature as I have shown here is a lobulos Centric granas inflammation which has been I think your uh the your lecture included it's included it very well so we have a lul Centric inflammation and we see around the uh of course as our radiologist said that initially when the patient presents an initial stage they can see the architecture maintained so that collaborates with the pathologic diagnosis also because the lobules are very well maintained uh in the most most of the times and we see a lobulo Centric inflammation with neutrophils there should be no necrosis these are the two pathognomic features which should clinch the diagnosis of Grom matus idopathic okay I just wanted to know that if you give us a core so many it is not possible that we get the lobular architecture intact so at that moment the pathologist may you know they may miss it they may just call it acute on chronic mesitis so this is a question to all the surgeons is it possible that we obtain a good chunk of incisal biopsy to get a proper diagnosis is it possible or is it doable um Dr Gita Dr anyone Dr anata Dr anupa it is possible but but it does mean that you know yeah most of the cases you know we get for review most of them have been diagnosed as acute on chonic mystis and definitely even on inal if the people are not aware of this condition or the type of the pathognomic features they definitely miss it so I mean at the first time defitely you know incisional biopsy we I mean it is possible but definitely it is more invasive than a COR biopsy and uh would definitely lead to scarring if the patient uh you know that is what you know more than that what happens with go ahead Dr yeah yeah go ahead anut yeah no I just wanted to say that if it is so important for us to get the correct diagnosis just doing an incision biopsy is quite okay you know I mean rather than missing out on the diagnosis again and again doing a repeat core some you do a repeat core also because you on the first core you got a acute and chronic mastitis so you know doing Trea I just wanted to add Dr Kavita um like being a radiologist do you think if we take more course that help us because in our Institute our theologists are able to give sorry yeah um our R our Pathologists are able to give us the diagnosis of IGM in a lot of cases and uh is the number of course that we are taking or from where exactly we are taking like for example rather than going into the necrotic or the the area of breakdown if we taking it more from the walls would that help so like you know I can see uh there is a little reservation among the surgeons to do an inational but why not try to improvise the already the current technique because a lot of us are getting it right also no I totally agree but mostly the biops is done at the periphery you know as you said that if you are keeping that condition in mind you're aware of that differential in mind you will definitely look up to areas where you know you find a viable this thing definitely more number of for if we get a l nothing like that yes I do I think that is the uh you know the critical thing is to do an image guided core biopsy obviously with people like Dr JY definitely they would do the you know great job uh Dr goel has raised his hand sir I just wanted to ask the panelist also say Dr Kavita mentioned that sometime we get a report of acute on chronic mtis so basically something which is not typically reported as a sort of Gran mtis but overall the clinical picture is let us say compatible because there is no no other sort of History suggestive of a recent acute episode or antibiotic therapy converting into a mix of acute and chronic then would you keep on repeating biopsies till you get granulomas or would you go with a combination of clinical radiological and whatever pathological information is available so that uh maybe the surgeons uh I would like their comment so if you ask me we do get this situation all the time you get an acute on chronic mtis report and you know I cannot possibly start her own steroids or even ask my Rheumatology colleague to you know think about an imuno modulator at that point of time So eventually what happens is after one month of trying various antibiotics and anti-inflammatories if it is still not working out I don't have an option other than to go ahead and operate that patient and it is on the final pathology that you get a chronic Romus mestis and then you go back to the drawing board and start of medical treatment again so Dr sorry um we had a couple of such patients they had acute on chronic and then um nothing was working and then the next time when they came we repeated them with VAB and then we got granus IGM in their diagnosis and then they were put on steroid and they complete this thing so that is also an option if uh if Co if the results are not uh you know the desired or uh a result which is fitting into the clinical and the radiological picture is not achievable in the first uh attempt then we can even think of that so how many course we should take I mean in place of if we are not doing in seasonal bsy how many course at at least actually really subjective as Dr ji said yes ultrasound guided would help I think the size or thickness of Poes matters uh because I believe that if if they are thickened thick C we are we will be more there there is a possibility that we get a lobu intact lobu or something like that basically yeah if I'm getting sinkers in full length then I sort of stop at four or five but if I'm getting very fragmented tissue necrotic tissue uh which is floating then I would even at times go to seven or eight so I see I I would see the quality of the course that I'm getting uh in my specimen bottle and uh you know I keep looking from the bottom how many of them have sank down and how many of them are full length so that helps me to decide when to stop and when I'm targeting I would not generally Target the center of the leion because that is where I'll get the necrotic tissue I would be targeting the wall of the uh of the leion other other thing I would like to bring to notice that we should start sending um a core uh one or two cores for TB pcrs also I think in for in normal saline in Saline right because we get in requisition we get requisitions that sended for DBP but the fixed specimens cannot work for the correct correct um I mean that's really actually important to obtain the appropriate sample for uh accurate diagnosis um my next question uh to you know all the surgeons is have you come across any uh such a situation where the initial diagnosis was the pathological uh reporting was acute on chronic mtis and we got a shock later on that it was actually indeed malignancy uh and not mestis have you come across any such situation not yet not ma'am I have come across one case she was a young female I also recently come across one okay go ahead ma'am we had by by chance we processed the entire Cy wall and a five negative breast cancer was sitting absolutely Dr that I saw was 3 she's 3 37 years old she recently came to me had an absis drained in April of 2023 so what she's saying is after that soon after the absis was drained she was well for about about two or three months but of course resing and all were happening and the VC report was um again acute on chronic mastitis it did not say IGM okay and then she continued to have a discharge and there was something hard was you know coming up but she was going to the same doctor uh they could not really uh so then uh she was referred to me and when I examined her of course there was a pange you know not very large area of pange but just at 12:00 there was a hard lump with um a limited P range and she we had a lymph node also and in fact the first biopsy from the lump I don't know for what reason it came back as negative because I think it did not hit Target but also asked for an fnac of the lymph node the lymph node was metastatic so we repeated the biy and we got an erpr positive her to negative so I think that is what is very important to you know I'm always can you mute uh personing yes sir Dr go yes ma'am can can I quickly go through this can Dr M be muted can I quickly go through this pran can you mute Dr mju yeah sure yes Dr kav so ma'am another the variant of granus mystis which I have seen just one case or I shall say I recognized one case till now cystic neutrophilic granus mystis and this case had come to us for a review again saying acute on chronic mystis and when I saw it I could see some ill formed granulomas which I'm sure would could have been easily missed by the pathologist okay and then I saw these lipid vacuums the clear spaces so you just click that could it be a differential I think I spoke to Dr G also how frequently you see cystic neutrophilic grtis mestis before I report it so I it up I took thick sections for Corine bacterium stain for sorry gr stain sorry to look for Corine bacterium and luckily we got gr positive although this is not the case this I took from internet but we had similar picture and my microbiologist confirmed that so the patient was taken I think she was given doxic cyclin for a long time the said that 6 Months 8 months the patient is okay she did not come back but I think this is one condition which should be definitely you should look for it I've recently seen one of cystic neutrophilic granus mestis and remembered that you told me this a separate entity but I not done this stain on her so maybe I should it is I mean the literature says that you know it is very difficult to C prove it on it has a different culture medium it has a different culture medium which is uh yeah right so uh now let us come to the treatment part and that's the most important part of you know today's discussion how do you proceed when you uh you know what has been your treatment algorithm um how do you take a decision about how to proceed with treatment uh anybody uh Dr Anan Dr anupma Dr Gita Dr Anan let's start with you how do you decide uh whether to start with antibiotic or steroids or how sir please unmute yourself so depending on the the presentation if there is a pass so we have P cultures and a and all types of cultures and if there is any evidence of any antibio I mean specific bacteria or so it will be a specific antibiotic otherwise we have choices of we have been discussing amoxy amoxy clavan or liazid liol flosin doxic or clomin so these are the choices depending on um cultures and all reports we use these antibiotics and then if it is a small uh in one quadrant then we prefer to give intal asteroids ultrasound guided intal we I mean in our department only we use our ult with our ultrasound in the evening same day in the OPD procedure after OPD we will do it and if it is large uh involving more more part of the breast I mean more than one quadrant then in that situation it may be a oral antibiotic but initially if there are signs of inflammation uh redness arithma then definitely antibiotic then later we go to the steroid thing okay and these are continuers we usually get these intal asteroids twice weekly and at least four to five times yeah most of the people they get use it monthly or three weekly we use it twice weekly and then four to five cycles and if when it it becomes stable then we don't give intal at that is the time when we have to take a choice whether uh we just keep these patients on followup or we go for surgical exision when it has localized Dr anupma yeah something similar so depending depending on the severity of the disease so if it is just a very mild you know a small lump not really causing much symptoms then we even uh give them antibiotics for about one to two weeks and keep them on followup just observation also call them again after a month and if it is moderate to severe cases that means large lumps and abscesses and all then obviously ultrasound guided aspirations and we start with oral steroids and uh oral steroids in the dose of 0.5 to 1 milligram per kg per day and uh the most important thing is telling the patient that this is going to take time 3 to six months usually is the time that it takes and to tell them to have patience for that time because otherwise you know they they just stop the steroids on their own and they go here and there they go around changing doctors and all that that happens so commonly that you end up with more problems later right so I guess the counseling is the most important part of the treatment of this disease yes so that's what was my next question was what was what has been the compliance of the patient to the treatment so you answered that uh Dr swagata is there any different uh you know approach you take for managing these patients um with steroid if it is not responding I give less steroid for less for one month only I give and it cured the uh sinuses uh for a enhanced healing and send the curtins again for tissue biopsy Etc to see if I have missed anything and recently in three or four of my patient I have started with the imuno modulator guchi and not yet in a condition to say whether it is really working because it is very few in number but I found very good results okay Dr gaita uh your uh you know use of steroid of choice intal or oral so I so just as Dr Anan said I would do it for a small lesion so if it is a 2 cm thing and you've been able to aspirate some of it put put her on antibiotics and then uh once the once you see that it has started to respond then I would do a steroid for that small lesion but if it is Big then I would do oral steroids after I've done a couple of weeks just as everybody else is doing a couple of weeks of um antibiotics the other thing that I've started doing now is I have found an ally in in a rheumatologist because I have realized that you know the uh and the results are great I'm very happy because you know the patient is also happy because there is another shoulder to cry on because you know it can it can be a very difficult disease to treat it giv confidence as well yeah yeah and they very and the rumatologist is very confident about bringing in various imuno modulators I I spoke to him and I said how do you decide when Methotrexate when hcqs he says there is an algorithm which they follow and they do it on a case- toase basis and I see that they use Methotrexate more freely than we would think they would start off with a 7.5 milligram weekly and put them on full white and all of that you know so they are taking care of the entire Spectrum so I hit upon this idea by Serendipity because I told you not because there is this patient who came with couple of patients who came with joint pains and I said okay let's let's seek the help of the rheumatologist and we realized that what he was doing was working well both in the breast and the joints you know so I have made this a regular practice now so the patient comes back to me only when there is an aggravation there is absis formation so there is one patient who I told you know who said malignancy on fnac so it's almost two years and there is a pattern to it she she says that every January end of January there is an aggravation so she has been with the rumatologist he has been taking care of all her you know the autoimmune bit and when now again she's developed an absis she came back to me I aspirated once and put her on antibiotics and once it settles up she goes back to the rheumatologist so it's a great relationship I think it is working very well for me and I'm sure I think we should all think about it so it is a known link actually approximately 8 to 14% of the patients you know they have Auto other autoimmune disorders like joint pains andema no and all that yes correct and um during this treatment how um frequently and with what modality do you monitor these patients for response um one by one maybe you it's it's a clinical clinical judgment I mean patient is improving patient says that lump has gone decreased there is an sinuses I have healed and um then clinical as then ultrasound is the other modality yeah all agree I suppose right and then that is how it helps us to uh modify the doses maybe add something else or uh you know administer more inational and all that that is how um is there any situation would where you would operate first um in in granul metas mesitis Dr Anand has already mentioned that uh when the patient has a large absis or fistula is there any condition or any any patient where you would operate when there is no sinus no fistula but you you want to say that patient presents with lump only in that situation that's what I'm asking when would you take a decision about surgery first so not truly initially we try this all modalities then only later on only s for the residual Legion all of you agree I think it is important for the patient also to understand this that everything possible to take care of in a conservative manner has not worked and then you operate and you know it is not as if surgery does not give you good results but the thing is you know we have to keep telling the patient look whatever I may do you're still going to come back and you're going to continue to change doctors also so I think that's okay um actually I want to come back to Dr JY uh Dr JY when we do say serial ultrasounds um what do we come uh to know about I mean how the patient is responding how does the you know ultrasound picture change um with treatment so if it is a unifocal obviously then the size is a a very good criteria so if it is unifocal one single lesion we'll see a decrease in the size there'll be reduction in the surrounding edema around uh around the leion but if it is multifocal you know those tubular branching pattern where they are interconnected with each other they can be at times when you have when you already have the knowledge of how many children are onyxis whe the Pati or but yes reduction in those branching hypogenic this start to collap the thickness of these wh reduces but what I generally tend to do is I would say that it is uh extending from say 9:00 to 1:00 position and then take multiple pictures so when in those cases um you know if there is a reduction in the outer um in the extent from nine it might now go to 10 and from one it is coming to say 12 then it's easier but this may not happen all the time you know there might be a peace Mill uh response and not concentric response so um it's the thickness of those branches but more importantly the edema goes down and we have to go back and see the images how the number of those areas of breakdown and they might have reduced now so that becomes a little bit difficult but then uh you know having saving good number of images and then going back and comparing we are able to tell that there there is a response right um if there is say uh to the clinicians uh this question is to the clinicians uh if the one particular patient say is found to be a non-responder as Dr jti mentioned that there are occasional cases where you know even clinically as well as on ultrasound you may not find uh the response which you are expecting then what has been U you know your next line of action a surgery or some other other like imuno other imuno supressant we have already discussed um is it surgery or what else do you so we try all the options actually so try oral steroids intralesional steroids immunosuppressants and in fact I've even tried Homeopathy I mean I don't give it but I refer to the consultant and uh you know i' I've discussed it with the Homeopathy consultant and they are quite confident about it because they do deal with the autoimmune diseases yes so they also start simultaneously while the patient is also on steroids and we both monitor it together so that also has helped in a few of my patients I mean I would say almost 10% of the patients it has helped I don't know because of Homeopathy or not but yes this is one option and surgery of course Remains the last option right so what has been the I I'm sure you all agree with what Dr anma says so so what to what ji said I think that is very important to understand you get these micro abscesses yes so these micro abscesses Are Walled off you can keep giving them pushing them antibiotics it just doesn't work and once you've seen that it is not working then the only option that only recourse then is surgery because you're not going to get away with it because it is going to keep flaring up keep subsiding keep flaring up because these microabscesses don't go away with the with those tracks ji mentioned and I think they keep on coming with the multiple discharging sinuses and the life of the patient is really hell so what has been the extent of the you know surgical procedure which you have been doing um um I mean the next question is of course have you ever done a momy for a patient with granus mestis not yet yet no okay no so um do you like do the debridment and removal of all the necrotic part and do you leave the uh you know raw area for secondary healing is that the option or you close the cavity over a drain or what has been your practice so close close the try to close the cavity I mean take a wider margin and try to close the cavity try to close the cavity that means you go for a very wide excision and all that is that so yeah that's so but that's the last option when you are not getting response from any any other uh so basically it's a combination you give antibiotics inton and then you start oral antibiotics and try to uh I mean make it uh the size you want to excise lesser Les lesser amount volume and when when you think that it is the now the least volume you are excising then only surgery is the option and uh we try to close it always but here we are talking about those where who are non-responders sir when the disease is quite extensive in that situation you are really in a fix as to how much to exercise and you end up uh you know causing lot of breast deformity isn't it yeah so we don't close I would I don't close I don't close either even I would pack the cavity yeah I would pack the cavity because you know you will see I'm sure you must have all counted it I think we all get wiser with time you know you could be packing the cavity and suddenly you'll see another lump coming up just adjacent to it absolutely absolutely this is and then and you know these are practical issues that you face and then you say oh God now what so you put in an artery through that open cavity you and try to drain that thing into the main cavity so you know we've all done done all of this but I think cosmetically your packing thing works well so I always say when you pack the cavity suppose it is a Perry aola or something try just try and place the nipple and you know you'll invariably find a lot of this happening around the nipple aola complex so I would raise the the nipple and keep it on top of the you know pack so that it doesn't dive in and you know then the deformity happens then you have to do a lot of mobilization when you're stitching it back but I would say four to six weeks of packing unfortunately this is what you're preparing your patient for when you're doing the conservative treatment that if worse comes to worse I have to operate because she's also seen that you've tried your best to treat treated conservatively not working and then when you finally do the surgery you're mentally preparing her for a 4 to 6 weeks of daily dressings which is quite a painful thing for the patient yes yes so obviously when there is pass or I me it's wet wet leion then only you will not close yeah definitely only if the lesion is very small and you know yes then I agree that you can maybe do a primary closure but those occasions are not very often we come across yeah so one more thing Vali I wanted to say in recent times we've started doing total duct excision along with whatever lumpectomy quadrantectomy we are doing absolutely because see everything the pathology starts from the ducts and I have realized that doing a total duct excision helps along with the debridment of all the necrotic tissue and theed area you mean in terms of preventing the recurr is that so okay yes absolutely absolutely so there have been few papers recently actually on this that total duct excision may be an answer to preventing a recurrence okay that's right um right so um you know we are actually coming closer to the uh but before we close I just wanted to understand from all of you um the literature says that it is a you know self-limiting condition but um I mean for me my patients I have not been able to you know follow any one particular patient for a long time so my understanding of about the natural history of this disease or the progression of the patients is actually very limited because patients usually do not come back to me so what has been your uh you know followup or experience in terms of how many patients do eventually get cured of this uh you know nasty problem and um what has been have you seen or followed some patients on a very regular basis and uh seen that this yeah they have now you know been cured of this disease yes yes oh yeah Ana you wanted to say please yeah so I would say uh after doing whatever we have to do approximately 60% patients would come back on followup 40% would be lost to follow up and amongst those 60% I would say at least half of them would be you know cured within a year approximately a year is an average time that I would say and that might include all the modalities of treatment uh any but any different I I I've had long I mean reasonable follow like I told you this patient of mine who about 3 years now she came only today with another thing coming up so you know you have I'm very clear in my mind I'm not actually thinking that it is going to be cured unless it is a small lesion which is likely to get cured but if it is a largest lesion there is every possibility that she's going to come back and you have to I keep instilling this also in my patients mind that it it has a waxing and waning pattern it is something and I said you can travel the whole world and you'll get the same answers the antibiotic may change but effectively you know most of the everybody is at their wids end as far as granus mesitis is concerned we keep making this effort to and I I you know anupa was actually had suggested a couple of years ago that you know we should be trying to run a trial wherein we put in all of these modalities see what uh an arm which has got antibiotics and steroids another one which has got the imuno modulators and a third one where there is surgery or something like that you know it could be it could have four arms and I'm sure with the kind of numbers that you're saying I think we should be able to give an answer to the rest of the world because the whole world is struggling with this I can assure you absolutely I also wish that something like this happens uh Dr goyel yeah I just had two or three questions which uh if you allow then I would just ask yes sir okay so firstly let me say Dr anopa how would you define cure in a patient of IGM how would you define cure so in a few papers that I've gone through including some metaanalysis on this issue uh approximately 12 months of no symptom uh similar to the earlier ones that she had so 12 months of remission complete remission is defined as cure so remission meaning absence of any lump or any symptoms total no symptoms at all complete resolution of the previous disease so no lump and no symptoms nothing nothing at all okay okay okay okay and uh Dr Gita do you think the incidence of IGM is increasing or we just become more aware we are making more diagnosis because of awareness or I I think you know more than half of these patients have gone on at earlier on but now I think you know we are making the effort to diagnose it and I think we're seeing it more often also it is not as if uh because you know I I remember in the last three or four years the incident is definitely seems to have grown because I'm seeing quite a bit and what anupa says is another you know because she she's seeing a lot more than we are seeing so I think there is something to the uh incidents growing incidents also and we don't know what would be the reason if the incidence is actually growing so that we don't know okay and Dr Anand let me ask the situation that a patient comes with the outside fnac report of uh carcinoma and then clinically you think it's actually not a malignancy then uh would a single biopsy which is negative give you the confidence to sort of reassure the patient or how do you feel confident enough to assure the patient that there is no malignancy actually obviously if patient has gone outside core bopsy or something then we will like to either review the blogs or slides or we will do a I mean s repeat bsy from that leion maybe palpable or ultrasound guided and once we are quite confirmed with your pathologist that it it doesn't have an malignancy then only be will assure the patient so basically if you are able to review outside material in case you're not able to review outside material and negative biopsy in your own setup is uh sufficient yes if we if imazing say says that imazing also we have to take into the consideration yeah yeah so I think I I would do it differently yeah yes what so if it is negative so I told you this patient came back with a came with a diagnosis of uh ductal carcinoma on FNA we did a biip categorically said chronic granus mesitis then I would stop but if it does not give just just as you said if the biopsy is negative then I would ear on the side of taking a yeah biopsy has to be negative for cancer biopsy has to be negative for cancer then there has to be something on the bapsi pathologist has if it's not there I'd rather go and operate her I because you know somebody coming with an fnac report of a ductal CA you know you have to do you have to make a better attempt to figure out what it is because I would not be comfortable leaving her alone so so the basic question is that fear even 1% fear of missing a malignancy somewhere in part of the breast that fear is going to be there so there was also this important because so many times you find a slightly sort of prominent or large lymph node so whenever you are going for a biopsy from the lump do you also ask for a FN from the lymph note I do I do yeah yeah so this is the situation which I was actually looking for when I asked you what what is the condition what is the particular specific situation where you would go for surgery you know surgical intervention first when you know there is a discrepancy between the outside report and the you know your institutional report um if it says negative then probably I would also rather you know operate on that patient and be 100% sure that uh you know you're not actually dealing with malignancy because that is what the situation we are going to really repent in you know Dr Joy you always do a f from a auxilary node in such cases or uh uh if the clinical uh like it depends what I'm seeing on Imaging if there is a a a clear-cut case of cancer and if the nodes are like you know really huge 4 five cm really palpable there is no highum then there is no doubt about it I wouldn't those patients have to go for clearance I would not go for an effiny for those but the ones which are indeterminate yes I would go but if it is a granulomas and the clinic uh the clinical picture the Imaging picture and the biopsies are saying that it is um granino then I know it is reactive nodes are expected then I don't go for a effiny for those but um when I am myself feeling that you know this can be malignancy I have a high suspicion of that then at the time of biopsy I would do a fnac also most of the times the picture is like uh with uh you know with our experiences we are getting wiser and wiser um so a lot of times I uh would say yes it looking more like granulometer so I would hold on I would not put a needle into lymph nodes but if I feel it's more likely to be cancer then I would put my needle into the axilla as well in the same setting no so basically as a surgeon it happens sometimes that we have a lump without sinuses and all and a prominent lymph node so in such cases even clinically we are sort of worried about malignancy so fnac from the node also being reported negative can give us a added level of comfort to reassure the patient that was the basic reason yeah yeah so suppose if on the Imaging I am getting a very clear-cut picture of absis yeah then I would not put a needle you would not but if I have I uh if the findings are not clearcut it could be either way then I'll put a needle into the node as well because all the cases of granus mastitis or for example any absis they would definitely be having enlarged lymph nodes so there is no point putting needles in those when we have a reason right there in the breast to suggest why this lymph node is enlarged okay but if I have a doubt like this can be you know many of times the necrotic tumors are looking like abscesses so if the so nowadays we have elastography as well and elasto helps us a lot so um if again I am pretty confident this will come back as absis then I would not put my needle in but if if I'm wrong and it comes back as cancer then in the second sitting I'll be going and putting a needle into the lymph nodes but not if if I'm pretty sure this looks like an absis then the uh the the reason of enlarged lymph nod is right in front of my eyes and biopsy has confirmed it so I'll hold on to axillary lymph node defy then okay ma'am can I ask a quick question small question yes please whenever you go for a lumpectomy what margin do you expect us I mean the is it 1 cm of the clear margin there's no U mention about any uh you know Marin no I I don't think in IGM you are talking about a clear margin as such and probably sacrificing too much of tissue may not be really worthwhile so removing all the gross lump and not really focusing on all the edema around maybe better in terms of the long-term cosmes and leaving the w't open to sort of heal by granulation might be a good approach that is what I feel personally yeah the the literature does say that you know taking the you know affected area with a healthy margin of breast tissue especially in you know smaller lesions has been form small different small but um there's no such uh you know to report because geten yeah yeah Dr anupa the patients who are Cur do you see a pattern in terms of what is the time in which the Cure is achieved is it that patients who are getting cured happen to have a early response and early cure Vis those who is this you're mute the severity of the disease will actually determine the time it takes for the Cure so obviously the milder cases I would expect a response in 3 to six months for them to be absolutely all right but uh these mild cases are very few in numbers what we see are actually the moderate ones or the severe ones who've like gone through a lot so for them I would uh tell them that it might take even up to a year for you to kind of get out of it maybe a year or more when would you decide to discontinue medical treatment uh say after response any further period of treatment uh so after response when we are assessing the patients on clinical examination as well as on ultrasound I should get a report from even from the sonologist saying that all the previous changes have resolved okay that would be the time that I would kind of you know uh I would of course start tapering earlier when when it is already resolving I would taper the steroids earlier and the medication but I would stop only after radiological remission is there sometimes it is very difficult because some small radiological changes residual changes they remain for long time is sympatic yes so what I do if the patient is asymptomatic virtually and a small like a centimeter centimeter and a half residual disease vual sort of changes are there which are stable over a period of next 2 or 3 months on ultrasound maybe today I have done I have repeated ultrasound after 8 weeks I think that is the time I should stop the treatment because I can't go on giving him sort of steroids or something Beyond a limit and of course yes has 20 to 30% patients 40% patient do recur sometimes and it is very difficult uh because now we have almost experienced of more than 50 to 200 cases in the last five six years so it's it's a very difficult situation on day one we have to explain to Patient it is easy I to treat cancer than gomas mestis that's and then how do you keep on monitoring uh do you get ultrasound done say at regular intervals to catch them at early recurrent stages or what do you do uh if two or three ultrasounds over a period of 6 months are stable we don't do anymore unless the patient becomes symptomatic because and even the patient will not come if they are not symptomatic yeah correct correct uh is there anything else so I think time is yeah Dr go can I request you to conclude yeah yeah yeah yeah thank you Dr Vali first for a comprehensive talk and then for a very comprehensive panel discussion I just chipped in uh for some personal queries of mine uh but I would like to thank uh all the faculty here Dr anopa Dr Gita Dr Swagat Professor Anan Dr Joy Dr Kavita I would like to sort of thank all the audience and uh the message is nearly 150 delegates have logged in in the program so overall a very enthusiastic response it basically it shows that this uh webinar model has a important role to play in the long run also and should stay uh uh because uh all meetings being physical is always a problem so it gives us an opportunity to connect with lot of people from lot of different places and the audience also from so many different places so this was the 31st uh webinar and we hope to continue bringing you uh more such interesting topics as we can find the thing is that after 30 webinars uh it is possible that we may have to recycle some of the earlier ones hoping which ones have new information to share so and thanks a lot to my ideas for doing a nice job thank you Dr Rajiv also in spite of being unwell you've been there continuously thank you thank you thank you thank you so much thank you thank you thank you