idiopathic granulomatous mastitis ( igm ) is an uncommon disease which usually arises in premenopausal women shortly after their last childbirth .
its etiology is unclear , however , breast - feeding and the use of oral contraceptives could exert an influence in its pathogenesis .
very often clinical and radiological findings mimic multifocal breast cancer   and the diagnosis is made by histopathology .
etiopathogenesis of igm often involves an inflammatory mechanism which could be resolved by the administration of corticosteroids or methotrexate , negating the requirement complete surgical excision .
cases of igm are related to the chronic use of selective inhibitors of serotonin reuptake ( ssri ) during antidepressant therapy are underestimated and should be treated with non - surgical therapeutic approaches .
the postulated causes have included autoimmune diseases such as granulomatous thyroiditis , granulomatous prostatitis , granulomatous orchitis , immune response to local trauma , local irritants , undetected organisms such as viruses , mycotic , and parasitic infections , hyperprolactinemia , diabetes mellitus , alpha-1 antitrypsin and the use of oral contraceptives .
interestingly , it has been reported that antipsychotic therapy can be associated with hyperprolactinemia   and that the onset of breast enlargement can occur during chronic antidepressant therapy   suggesting a possible side effect of ssri .
in particular ssri could exert a perturbation in dopamine secretion , counteracting its role in repressing prolactin gene expression , leading finally to hyperprolactinemia and associated igm . in this regard
, it seems worthy of noting the findings about a functional crosstalk between serotonin and dopamine receptors . in our opinion ,
surgical excision of the lesion is not necessary in cases of antidepressant therapy - related igm , and where possible , a conservative approach based on administration of an antiinflammatory therapy is favored .
histopathological confirmation , combined with exclusion of malignancy and other causes of granulomatous disease , is of great importance in guiding clinical decision making and preventing inappropriate and unnecessary treatments . a retrospective study by erhan et al .   reviewed
delayed wound healing or recurrence after excisional biopsy , or those who have had an incisional biopsy only , if prolactin level was normal , reexcision and oral prednisone usage may be curative . in patients with a high prolactin level and who had recurrence , medical treatment to control prolactin levels
this study seems , therefore , to underline an unexpected and underestimated prognostic value of blood prolactin levels , which could exert an interesting role in the recurrence of igm .
as hyperprolactinemia can be induced by ssri , whose chronic use can cause gm , in these particular cases the ideal management of patients is not surgical excision , given that lesions are not malignant , but are probably caused by an hypersecretion of prolactin by the pituitary gland related to alteration of serotonin / dopamine metabolism . if this pathogenetic hypothesis is validated it could be reasonable to propose a suspension of ssri therapy to monitor the evolution of breast lesions , which would regress spontaneously , or alternatively
, a therapy aimed to control prolactin blood levels and/or to modulate inflammation could be achieved .
igm raises important diagnostic and therapeutic dilemmas , as more than 50% of the reported cases are initially mistaken for breast carcinoma .
occasionally some patients may be subjected to mastectomy as a consequence of a false positive fine - needle aspiration cytology ( fnac ) result , as has been previously reported .
the practice of performing mastectomy merely on the basis of triple assessment ( clinical , mammographic , and fnac findings consistent with malignancy ) , therefore , does not seem to be necessarily justified . in this paper
we emphasize the importance of diagnosis of igm , which in the non malignant forms should not be treated surgically .
in particular we draw attention to cases of igm related to antidepressant ( ssri ) therapy , postulating that these clinical scenarios must also be approached conservatively .
 granulomatous mastitis is a rare benign inflammatory disease of the breast with multiple etiologies such as tuberculosis , sarcoidosis , foreign body reaction , and mycotic and parasitic infections . 
 in contrast , idiopathic granulomatous mastitis ( igm ) is characterized by the presence of chronic granulomatous lobulitis in the absence of an obvious etiology . 
 clinically and radiologically it may mimic breast carcinoma and so awareness of surgeons , pathologists , and radiologists is essential to avoid unnecessary mastectomies . 
 cases of igm are reported during antidepressant therapy in patients also showing high levels of prolactinemia . in these cases 
 , we believe that surgical excision must be avoided being replaced with a conservative management of the pathological condition based on a corticosteroid treatment . 
INTRODUCTION
HYPOTHESIS: SSRI COULD ALTER PROLACTIN SECRETION LEADING TO GRANULOMATOUS MASTITIS
EVALUATION OF HYPOTHESIS AND DISCUSSION: ANTIDEPRESSANT THERAPY-RELATED GRANULOMATOUS MASTITIS DOES NOT REQUIRE SURGICAL INTERVENTION
CONCLUSION