Adil, it’s great to have you here because this is a little bit of a departure from this National Cancer Institute Directors meeting here in Lyon but you’ve got some special news on a relatively rare condition, a benign breast disease, granulomatous mastitis. Why are you so interested in this? I know you’ve just published on it, haven’t you?

Yes, indeed. This was published a few months back in the Sultan Qaboos University Medical Journal. The reason, in fact, is a very good question. This disease, in spite of being a benign disease, sadly some patients, they have to undergo very mutilating treatment such as a mastectomy for such a benign disease which I think is unfair. So because this disease is being tackled from different issues and treated by different modalities, starting from steroids, you know steroids have a lot of complications and side effects, using all these different modalities they did not show good results. Although some publications show some improvement but they have a lot of side effects.

Now, first of all diagnosis, is that simple?

Well not indeed, because in many hospitals they underestimate the role of triple assessment. What I mean by triple assessment, triple assessment means history examination, imaging and histopathology. Many centres they just do history examination, maybe imaging and they rely on their clinical experience that it is infection, there is pus, there is erythema so it is infection, just treat as infection without knowing what type of infection. Because infection can be acute, you can readily treat that, or chronic such as in this case in which really patient and surgeon face difficulties to treat.

So what’s your first bit of advice for doctors faced with a condition which may well be granulomatous mastitis?

Go for triple assessment, not only for this for any breast abnormalities. In fact this is text book advice and if you follow this you come to the diagnosis. Once you’ve got the diagnosis you can treat. Again, treatment of this type of disease is very controversial.

The controversy being that you can be over-aggressive.

Some people, yes. Some people go as low as steroids in spite of the ready availability of steroids but of course it has enormous complications. Then some of them go to chemotherapy and to a far extent with a mastectomy.

Now in contrast with that you’ve published on this, what have you found to be the optimum management for this benign breast disease?

Indeed. This paper which we published is the second biggest series in the world. It is very conservative management.

What did you do?

It is infection, how do you treat infection? It is antibiotics. Some people talk about autoimmune; with this study which we have done we ruled out the role of autoimmune, we ruled out, in some countries like Asian countries where they have tuberculosis and they associate tuberculosis, like in India, blindly whenever they have this type of disease because granulomatous mastitis can be either caused by TB or by other things. But the majority are idiopathic, in this case it means unknown reason or unknown origin. So I think it’s unfair to treat something which is idiopathic with anti-TB.

So what sort of anti-microbial strategy did you follow?

Well done. In fact, once these patients come we do a culture for all patients, we sent tissue either for histo- and microbiology and we based on clinical findings that this is an infection and has not any autoimmune underlying cause. So we treat it with broad spectrum antibiotics of two types, anaerobic and aerobic, for a long period. It is chronic so with chronicity you have to take a longer period of treatment. We cover patients with aerobic two weeks, anaerobic antibiotics four weeks. The patients get an excellent response within six weeks’ time. To extend that, the breast was normal in three months’ time. In fact, all treatment has side effects, the only side effect which we faced in this one is two cases out of thirty we had recurrence and these recurrences were treated similarly with a further course of antibiotics.

The same antibiotics or different ones?

Indeed, yes, the same one. The same one and patients were well after a few weeks. Up to now we have more than three years follow-up; all patients are recurrence free.

And you said that this is the second largest series in the world.

Indeed, the second.

How many patients have you treated?

Thirty, thirty cases. In fact we are now… the number of patients are sixty. In a few years’ time we will publish another paper with a longer follow-up.

So what is your bottom line clinical message to doctors faced with a case which might well be granulomatous mastitis then?

Well, make sure that this is a diagnosis, keep your knife away. I know you are a surgeon, you have a tendency to use knives, use it wherever is needed. I think granulomatous mastitis you need to be careful, gentle, avoid aggressive treatment because surgery might lead to complications such as fistulae and fistulae are a nightmare for the patient. So I advise make a diagnosis based on triple assessment; once the diagnosis is made be conservative. Treat with antibiotics, keep the knife away.