1000-2000 5 ьшò

FOLLOW-UPRECOMMENDATIONS

Condition is benign, chronic, and recurrent.

Patient Monitoring

Follow-up times are variable, depending on the clinical situation and pertinent family history.

US is useful to differentiate cysts from solid lesions and in evaluating women <35 years of age for FCC but is not useful for screening.

Screening mammograms: Refer to the USPSTF, ACOG, or ACS recommendations for screening schedules.

DIET

The role of caffeine consumption in the development and treatment of FCC has never been proven; however, some patients report relief of symptoms after abstinence from coffee, tea, and chocolate.

PATIENT EDUCATION

Patient information on fibrocystic breasts from the Mayo Foundation for Medical Education and Research: www.mayoclinic.com/health/fibrocysticbreasts/DS01070

Information on breast cancer prevention from the National Cancer Institute: www.cancer.gov

Information on fibrocystic breasts from the American Cancer Society: www.cancer.org/Healthy/FindCancerEarly/WomensHealth/Non- CancerousBreastConditions/non-cancerous-breast-conditions-fibrocystic- changes

REFERENCES

1.Pearlman M, Griffin J, Swain M, et al; for American College of Obstetricians and Gynecologists’Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 164: diagnosis and management of benign breast disorders.

Obstet Gynecol. 2016;127(6):e141–e156.

2.Hartmann LC, Sellers TA, Frost MH, et al. Benign breast disease and the risk of breast cancer. N Engl J Med. 2005;353(3):229–237.

3.Horner NK, Lampe JW. Potential mechanisms of diet therapy for fibrocystic breast conditions show inadequate evidence of effectiveness. J Am Diet Assoc. 2000;100(11):1368–1380.

4.Srivastava A, Mansel RE, Arvind N, et al. Evidence-based management of

mebooksfree.com

mastalgia: a meta-analysis of randomised trials. Breast. 2007;16(5):503–512.

5.Mousavi SR, Mousavi SM, Samsami M, et al. Comparison of tamoxifen with danazol in the management of fibrocystic disease. Int J Med Sci. 2011;2:329– 331.

6.Bruening W, Fontanarosa J, Tipton K, et al. Systematic review: comparative effectiveness of core-needle and open surgical biopsy to diagnose breast lesions. Ann Intern Med. 2010;152(4):238–246.

ADDITIONALREADING

Amin AL, Purdy AC, Mattingly JD, et al. Benign breast disease. Surg Clin North Am. 2013;93(2):299–308.

Barton MB, Harris R, Fletcher SW. The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA. 1999;282(13):1270–1280.

Griffin JL, Pearlman MD. Breast cancer screening in women at average risk and high risk. Obstet Gynecol. 2010;116(6):1410–1421.

Jatoi I. Screening clinical breast examination. Surg Clin North Am. 2003;83(4):789–801.

Klein S. Evaluation of palpable breast masses. Am Fam Physician. 2005;71(9):1731–1738.

Meisner AL, Fekrazad MH, Royce ME. Breast disease: benign and malignant. Med Clin North Am. 2008;92(5):1115–1141.

Morris EA. Diagnostic breast MR imaging: current status and future directions. Magn Reson Imaging Clin N Am. 2010;18(1):57–74.

Rinaldi P, Ierardi C, Costantini M, et al. Cystic breast lesions: sonographic findings and clinical management. J Ultrasound Med. 2010;29(11):1617– 1626.

Santen RJ, Mansel R. Benign breast disorders. N Engl J Med. 2005;353(3):275–285.

Saslow D, Boetes C, Burke W, et al; for American Cancer Society Breast Cancer Advisory Group. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57(2):75–89.

CODES

mebooksfree.com

ICD10

N60.19 Diffuse cystic mastopathy of unspecified breast

N60.09 Solitary cyst of unspecified breast

N60.29 Fibroadenosis of unspecified breast

CLINICALPEARLS

FCC of the breast comprise a spectrum of histopathologic changes are a common finding in reproductive-aged women. The former term of fibrocystic disease is a misnomer.

Atypia, as demonstrated histopathologically, confers an increased cancer risk.

NSAIDs are the first-line treatment.

OCPs, danazol, and tamoxifen are second-line treatments, with considerable adverse effects.

Consultation with a breast specialist is recommended for symptomatic disease refractory to simple measures, or for diagnostic issues.

mebooksfree.com

FIBROMYALGIA

F. Stuart Leeds, MD, MS

BASICS

DESCRIPTION

Chronic, widespread noninflammatory musculoskeletal pain syndrome with multisystem manifestations. Although the specific pathophysiology has not been elucidated, it is generally thought to be a disorder of altered central pain regulation.

Synonym(s): FMS; fibrositis, fibromyositis (misnomers); “psychogenic rheumatism” (archaic and inaccurate)

EPIDEMIOLOGY

Incidence

Predominant sex: female (70–90%) > male (1)

Predominant age range: 20 to 65 years

Prevalence

2–5% of adult U.S. population (2); 8% of primary care patients

ETIOLOGYAND PATHOPHYSIOLOGY

Idiopathic; appears to be a primary disorder of central pain processing (central sensitization) with afferent augmentation of peripheral nociceptive stimuli

Alterations in neuroendocrine, neuromodulation, neurotransmitter, neurotransporter, biochemical, and neuroreceptor function/physiology

Sleep abnormalities—α-wave intrusion

Inflammation is not a feature of fibromyalgia.

Genetics

Genetics

–High familial aggregation

–Inheritance is unknown but likely polygenic.

–Odds ratio may be as high as 8.5 for a first-degree relative of a familial

proband.

Environmental—several triggers have been described:

mebooksfree.com

–Physical trauma or severe illness

–Stressors (e.g., work, family, life events, and physical or sexual abuse)

–Viral and bacterial infections

RISK FACTORS

Female gender

Poor functional status

Negative/stressful life events

Low socioeconomic status

GENERALPREVENTION

No known strategies for prevention

COMMONLYASSOCIATED CONDITIONS

Often a comorbid condition with other rheumatologic or neurologic disorders Obesity is common and associated with increased severity of symptoms.

DIAGNOSIS

Original 1990 ACR criteria, still widely used: (i) pain in all four quadrants, (ii) axial (neck/spine) involvement, (iii) tender points (TPs) ≥11, (iv) no other explanation for symptoms (2)

2010 revised ACR criteria (2)

–Based on Widespread Pain Index (WPI) and Symptom Score (SS) Must have WPI ≥7 + SS ≥5 or WPI ≥3 and SS ≥9; and

Symptoms for >3 months; and

No other explanation for these symptoms

WPI/SS patient scoring and diagnosis tool: https://www.umassmed.edu/uploadedFiles/cme/CME_Members_Area/C1- Handout-Fibromyalgia.pdf

The Visual Analogue Scale Fibromyalgia Impact Questionnaire (VASFIQ) is recommended for initial and serial assessment of patient’s functional status: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383533/figure/fig11759720X11416863/.

Enhancements to the 2010 criteria, termed 2011modCr and 2013altCr (2), have been proposed but are not yet widely accepted.

HISTORY

mebooksfree.com

Universal symptoms include

–Chronic widespread pain ≥3 months: bilateral limbs and in the axial skeleton

–Fatigue and sleep disturbances

Often present:

–Mood disorders, including depression, anxiety, and panic symptoms

–Cognitive impairment: qualitatively different from that seen in isolated mood disorders (“fibro fog”)

–Headaches: typically, tension and migraine types

–Other regional pain syndromes, such as irritable bowel syndrome, chronic pelvic pain, vulvodynia, and interstitial cystitis

–Paresthesias, often “nonanatomic”

–Exercise intolerance, dyspnea, and palpitations

–Sexual dysfunction

–Ocular dryness

–“Multiple chemical sensitivity” and an increased tendency to report drug reactions

–Impaired social/occupational functioning

–Symptoms can wax and wane on a day-to-day basis, varying in quality, intensity, and location.

PHYSICALEXAM

Classic fibromyalgia TPs: 9 symmetric pairs (5 anterior, 4 posterior). Diagram available from: http://tinyurl.com/fibroTP

The presence of ≥11 TPs carries a sensitivity of 88.4% and specificity 81.1% for the disease (2).

TPs in fibromyalgia are distinct from the “trigger points” found in myofascial pain syndromes and are not sites for therapeutic injection.

Examine joints for swelling, tenderness, erythema, decreased range of motion, crepitus, and cystic or mass lesions. These are typically absent in fibromyalgia.

Document absence of inflammatory features (e.g., no synovitis, enthesopathy, dermatologic or ocular findings).

Neurologic exam: may demonstrate generalized or “nonanatomic” dysesthesia, hyperor hypesthesia

DIFFERENTIALDIAGNOSIS

RA, SLE, sarcoidosis, and other inflammatory connective tissue disorders Diffuse/advanced OA

mebooksfree.com

Seronegative spondyloarthropathies (AS, psoriatic arthritis, etc.)

Polymyalgia rheumatica

Inherited myopathies

Drug-induced and endocrine myopathies

Viral/postviral polyarthralgia

Anemia and iron deficiency

Electrolyte disturbances: Mg, Na, K, Ca

Obstructive sleep apnea

Restless leg syndrome

Osteomalacia/vitamin D deficiency

Opioid-induced hyperalgesia

Hypothyroidism

Multiple sclerosis

Lyme disease

Hepatitis B and C (chronic)

Inclusion-body myositis

Spinal stenosis/neuropathies

Generalized muscular deconditioning

Peripheral vascular disease

Somatoform disorder Overlap syndromes

–Chronic fatigue syndrome/chronic fatigue immune dysfunction syndrome (CFIDS)

–Myofascial pain syndrome (more anatomically localized than fibromyalgia, but they may co-occur)

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

CBC with differential, ESR or CRP, CPK, TSH, comprehensive metabolic profile; consider 25-OH vitamin D, Mg, B12, folate, and urine drug screen

ANA, RF, and other rheumatologic labs generally unnecessary, unless there is evidence of an inflammatory connective tissue disorder.

Imaging is not indicated, except to exclude other diagnoses.

Diagnostic Procedures/Other

Sleep studies may be indicated to rule out obstructive sleep apnea or narcolepsy.

Consider psychiatric or neuropsychiatric evaluation for mood disorders and

mebooksfree.com

cognitive disturbances.

TREATMENT

Evidence-based interventions include (3):

Nonpharmacologic treatment are central to successful outcomes. Patients should be active participants in their care, especially with exercise and lifestyle.

Regular exercise and sleep hygiene are foundational to improved outcomes. Nonpharmacologic

–Educate about diagnosis, signs, symptoms, and treatment options: On-line resources include:

www.fmaware.org https://www.fmcpaware.org/ http://www.fibromyalgiaforums.org/ http://www.livingwithfibro.org/

–VASFIQ for initial assessment and interval evaluation during treatment

–Cognitive-behavioral therapy improves mood, energy, pain, and functional status.

–Aerobic exercise: moderately intense, with gradual progression to minimize symptom exacerbation

–Weight loss may augment the benefits of exercise.

–Strength/resistance training—mild to moderate

–Aquatic exercise training

–Sleep hygiene

–Mitigate tobacco, alcohol, and substance use.

Pharmacologic

–Three FDA-approved drugs: duloxetine, milnacipran, and pregabalin; others are off-label.

–Caution: Fibromyalgia patients are frequently treated with multidrug therapy; monitor for drug interactions, sedative, and anticholinergic burden.

MEDICATION

First Line

Amitriptyline 10 to 50 mg PO at bedtime to treat pain, fatigue, and sleep disturbances (4)[A]

Duloxetine initially 30 mg/day for 1 week and then increase to 60 mg/day as tolerated. Taper if discontinued (4)[A].

Milnacipran day 1: 12.5 mg/day; days 2 to 3, begin dividing doses: 12.5 mg

mebooksfree.com

BID; days 4 to 7: 25 mg BID; after day 7: 50 mg BID; max dose 100 to 200 mg BID. Taper if discontinued (4)[A].

Pregabalin: Start with 75 mg BID, titrate over 1 week to 150 mg BID; max dose 450 mg/day divided BID–TID (4)[A]

Cyclobenzaprine 5 mg qHS; titrate to 10 mg BID–TID as tolerated (3)[B].

Second Line

Gabapentin: Start at 300 mg HS, titrate to 1,200 to 2,400 mg/day divided BID–TID; max dose 3,600 mg daily (3)[B]

Venlafaxine: XR 37.5 to 225 mg; likely to be as effective as other SNRIs (duloxetine, milnacipran)

Tramadol 50 to 100 mg q6h; likely more effective in combination with acetaminophen (3)[C]

Quetiapine 25–100 mg qHS (5)[B]

Several investigational agents show some promise of benefit, including, naltrexone, sodium oxybate, cannabinoids, and pirlindole (5).

Cholecalciferol may be beneficial in patients with low 25-OH vitamin D levels.

Use of two or more agents may be more effective than monotherapy. Watch for overall sedative and anticholinergic burden.

Trigger point (not Tender Point) injections for regional myofascial dysfunction may provide relief (6).

Alert

Ineffective or dangerous treatment modalities

NSAIDs, full-agonist opioids (except in refractory cases), benzodiazepines, SSRIs (may have efficacy in combination therapy), magnesium, guaifenesin, thyroxine, corticosteroids, DHEA, valacyclovir, interferon, calcitonin, and antiepileptic agents (other than those listed above) (5)[A]

Fibromyalgia often presents concurrently with other pain syndromes that may respond to NSAIDs, corticosteroids, opioids, and other agents.

COMPLEMENTARY& ALTERNATIVE MEDICINE

Acupuncture and electroacupuncture, biofeedback, hypnotherapy

Balneotherapy (mineral-rich baths)

Yoga, tai chi, and qi gong—improve sleep, fatigue, and quality of life but may not decrease pain

mebooksfree.com

Limited double-blind trials have shown effectiveness of supplementation with

S-adenosyl methionine and acetyl-L-carnitine.

Some evidence for transcranial direct current or magnetic stimulation and repetitive transcranial magnetic stimulation

Likely to be ineffective: chiropractic treatment, massage, electrotherapy, ultrasound

ISSUES FOR REFERRAL

In cases of unclear diagnosis or poor response to therapy, refer to rheumatology, neurology, and/or pain management

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

For efficacy of initial therapy: at 2- to 4-week intervals; then every 1 to 6 months, tailored to patient’s needs

Advance exercise gradually to maintain tolerability.

DIET

No specific diet is recommended, but patient should be urged to make healthy choices and address negative dietary habits. Caloric or carbohydrate restriction may be helpful in obese patients.

PROGNOSIS

50% with partial remission after 2 to 3 years of therapy; complete remission possible but rare.

Typically has fluctuating, chronic course

Poorer outcome tied to greater duration and severity of symptoms, depression, advanced age, lack of social support

REFERENCES

1.Wolfe F, Häuser W. Fibromyalgia diagnosis and diagnostic criteria. Ann Med. 2011;43(7):495–502.

2.Bennett RM, Friend R, Marcus D, et al. Criteria for the diagnosis of fibromyalgia: validation of the modified 2010 preliminary American College

mebooksfree.com