Case Report: Management of refractory granulomatous lobular mastitis with precision surgery and local irrigation.

Background: Granulomatous lobular mastitis (GLM) is a rare chronic inflammatory breast disease with a high propensity for recurrence. Refractory cases that involve extensive abscess formation, sinus tracts, and failure of medical therapy remain difficult to manage. Case presentation: A 39-year-old multiparous woman presented with a left breast mass that had first been noticed approximately 6 months earlier and had progressively enlarged to involve multiple quadrants. The disease was complicated by abscess formation, areolar ulceration, and sinus tracts. Prior treatment with anti-inflammatory therapy, a course of oral corticosteroid, and a 4-month course of traditional Chinese medicine produced no durable improvement, and the mass subsequently ulcerated. Preoperative evaluation identified hyperprolactinemia and a Rathke cleft cyst on pituitary magnetic resonance imaging. Intervention and management: After preoperative prolactin control with bromocriptine, the patient underwent parenchyma-sparing surgery with thorough debridement of necrotic tissue across multiple quadrants. Mildly edematous glandular tissue and clinically involved ducts were preserved and opened to facilitate postoperative drainage. After glandular flap reconstruction, the surgical cavity was irrigated daily through two indwelling drains with 250 mL of normal saline containing dexamethasone acetate, initiated at 20 mg; the dose was reduced by 5 mg (one ampoule) every 3 days to a final dose of 5 mg, after which the cavity was rinsed with normal saline alone until the drains were removed. Syndrome-differentiated oral traditional Chinese medicine was given throughout the postoperative course. Results: The drainage fluid became clear and the drains were removed without residual purulent or necrotic material. Serial postoperative ultrasonography demonstrated progressive resolution of the inflammatory changes. At the 2-month follow-up, clinical examination showed no residual disease or recurrence, and the cosmetic outcome was satisfactory; the patient remained free of clinical recurrence during continued outpatient follow-up of approximately 2 years. Conclusion: Parenchyma-sparing surgery combined with local corticosteroid irrigation achieved short-term local control in a refractory case of GLM. The preliminary result warrants confirmation through longer follow-up and larger prospective studies.