| PART I The Investigation of the Expression of IgG4、TNF-α、IL-1β、IL-6、PRLR in Granulomatous lobular mastitisObjective: To investigate the expression of IgG4,TNF-α,IL-1β,IL-6 and PRLR in granulomatous lobular mastitis(GLM)and to explore a new idea of its pathogenesis.Methods: 38 patients with GLM were collected from Tongji Hospital affiliated to Huazhong University of Science and Technology from August 2017 to October 2019.They were tested the level of IgG4,TNF-α,IL-1β,IL-6 and PRL in peripheral blood.The pathological specimens of GLM patients and patients with Plasma cell mastitis(PCM)and benign non-infectious breast diseases treated with surgery in our hospital were collected.According to the pathological diagnosis,patients were divided into three groups,GLM group of 38 cases,PCM group of 16 case and normal breast tissue group(above 2cm around the tumor of benign breast disease)of 12 cases.Immunohistochemical staining was used to detect the expression of IgG4,TNF-α,IL-1β,IL-6 and PRL in the samples of the above cases respectively.The relationship between clinical biochemical characteristics and clinical factors of GLM was further studied,detecting the expressional differences of five indicators in different disease periods and different age groups.Results:1.The results showed that positive expression rate and comprehensive score of IgG4,TNF-α and IL-6 in the tissues in GLM patients were significantly higher than those in the PCM patients(p<0.05),while IL-1β and PRLR showed no obvious changes compared with the PCM group(p>0.05).The positive expression rate of IgG4,TNF-α,IL-1β and IL-6 in normal breast tissue were very low,which was significantly different from the GLM group(p<0.05).However,the expression of PRLR in the GLM group and normal breast tissue was consistent,with no statistical difference(p> 0.05).2.There is an obvious difference at the different disease periods of TNF-α.The expression of TNF-α in the abscess period is significantly higher than lump period(P<0.05).3.The expression of five indicators in GLM patients was basically the same in the age group with high incidence of disease(28-36 years old)and the age group without high incidence of disease(less than 28 years old and more than at 36 years old),with no significant statistical difference(p>0.05).4.In the peripheral blood test of 38 GLM patients,five patients with increased IgG4,eight patients with increased TNF-α,two patients with increased IL-1β and ten patients with increased IL-6,while PRL was within the normal range.The levels of IgG4,TNF-α,IL-1β,IL-6 and PRL in peripheral blood were consistent between tumor stage and abscess stage,with no statistical difference(p>0.05).Conclusions:1.The expression of IgG4,TNF-α and IL-6 in GLM patients is significantly higher than that in PCM patients.Except that the expression of PRLR in GLM patients is consistent with that in normal breast tissue,there are significant differences in the expression of other four indicators.This indicates that the occurrence of GLM is related to the participation of IgG4,TNF-α and IL-6 and further confirmed that GLM may be an autoimmune disease,which should be treated clinically with medical treatment as the leading principle and surgical treatment as the auxiliary principle..2.The expression of TNF-α in patients with GLM in the abscess stage is higher than that in the mass stage,indicating that the expression of TNF-α increased with the progress of the disease.It suggests that TNF-α may play an important role in the occurrence and progress of GLM.There is no significant difference in the level of TNF-α in peripheral blood between the abscess stage and the mass stage,indicating that the level of TNF-α in peripheral blood could not reflect the severity of GLM.PART II The clinical combination treatment of glucocorticoid and total glucosides of paeony in Granulomatous lobular mastitisObjective: To investigate the efficacy of combination treatment of glucocorticoid and total glucosides of paeony(TGP)in GLM and find a better treatment,which could reduce the recurrence rate of GLM and the dose of glucocorticoid and improve the side effects of drugs.Consequently to explore the feasibility of the principle of medical treatment as the main treatment and surgical treatment as the auxiliary treatment in GLM,and whether surgical intervention is needed in the process of medical treatment and when the surgical treatment should intervene in the treatment process.Methods: The patients diagnosed with GLM by core needle biopsy were recruited from Tongji Hospital affiliated to Huazhong University of Science and Technology from August 2017 to October 2019.Patients who had achieved other treatment were excluded.Their BMI,reproductive age,breastfeeding history and other basic information were recorded.According to different treatment,the patients was divided into three groups: combination treatment group of glucocorticoid and TGP,treatment group of glucocorticoid alone and treatment group of TGP alone.The breast ultrasound were reviewed every 2-4 weeks and the tumor size,changes in clinical manifestations and side effects of the drugs were recorded.After the end of the therapy,the efficacy differences of the three groups were compared.Results:1.38 patients diagnosed with GLM were recruited in our study,but 2 patients were lost to follow-up and the treatment was discontinued in 3 patients.The average age of the patients was 32.04±4.93 years old and the average BMI was 24.08±3.60 kg/ m~2.There were 36 patients who had given birth,2 patients who had not given birth,2 patients who had abortion history.The average child-bearing age of was 26.89±3.23 years old.There were 33 cases of breast-feeding,with an average duration of 10.71±4.86 months.All patients were treated for the first time.They had no previous history of lactation mastitis,no previous medical history and no history of smoking and drinking.2.In the enrolled patients,the average breast mass size was 4.81±1.67 cm.13.16% of the patients were accompanied by skin redness and swelling,92.11% of the patients were accompanied by breast pain,47.37% of the patients had abscess and 5.26% of the patients with intradermal nipple.In addition,2 patients presented with extramammary symptoms,presenting with erythema nodosum and associated with joint swelling and pain in lower extremity.3.Finally,33 patients completed the treatment in our study and the total effective rate was 60.61%.Among them,15 patients were treated with combination treatment,11 patients were treated with glucocorticoid alone,and 7 patients were treated with TGP alone.The results showed that the combination treatment had a better therapeutic effect than other two treatment group,with the effective rate of 86.67%.The effective rates of the glucocorticoid alone group and the TGP alone group were 45.45% and 28.57% respectively.The results showed that the therapeutic effect of the experimental group was obviously higher than that of other two groups(P<0.05),which was statistically significant.4.Surgical interventions were given to 5 patients after the progression of disease,among which 4 patients treated with irrigation by 0.9% sodium chloride solution to flush the abscess cavity,1 patient adopted incision and drainage.After four weeks,the conditions of the 5 patients improved a lot.Conclusions: The treatment of TGP alone is not suitable for the treatment of GLM in acute-outbreak period,while the combination treatment with glucocorticoid has higher effective rate and lower recurrence rate,which is better than the treatment with glucocorticoid alone.We think that the treatment of GLM should follow the principle of medical treatment mainly and surgical treatment as auxiliary.We should use combination treatment to control symptoms in the early stage of GLM and maintain the efficacy with TGP in the later stage.Depending on whether the patient has a condition that requires surgical intervention,we provide surgical auxiliary treatment based on irrigation treatment and local excision for them. |
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