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200 | Management of Disorders of the Ductal System and Infections | ETIOLOGY | null | nan nan | 51 | 6 | 0.0234 | 0.0678 | 0.0982 | 0.0982 | 0.0982 | 0.0982 | 0.0982 | 3 |
201 | Management of Disorders of the Ductal System and Infections | ETIOLOGY | null | nan nan | No histologic differences have been detected in biopsies from women with and without mastalgia. Immunohistochemical examination of biopsies from 29 women with mastalgia and 29 control subjects revealed no differences in expression of interleukin-6, interleukin-1, and tumor necrosis factor. | 6 | 0.05 | 0.075 | 0.08 | 0.04 | 0.03 | 0.005 | 0.08 | 3 |
202 | Management of Disorders of the Ductal System and Infections | CLASSIFICATION | null | nan nan | Preece et al. (8) proposed a classification with six subgroups based on a prospective study of 232 patients with breast pain: cyclic mastalgia, duct ectasia, Tietze’s syndrome, trauma, sclerosing adenosis, and cancer. This was subsequently sim- plified into two groups with noncyclic pain: true noncyclic breast pain and those with other causes of chest wall pain | 6 | 0.01 | 0.095 | 0.07 | 0.06 | 0.04 | 0.08 | 0.095 | 2 |
203 | Management of Disorders of the Ductal System and Infections | CLASSIFICATION | null | nan nan | (9). Although an accurate diagnosis can be achieved on the basis of history and examination, patients with breast pain can be more simply assigned to one of three groups: cyclic breast pain (around 70%), noncyclic breast pain (20%), or extramammary pain (10%). | 6 | 0.07 | 0.085 | 0.06 | 0.04 | 0.03 | 0.01 | 0.085 | 2 |
204 | Management of Disorders of the Ductal System and Infections | CLASSIFICATION | null | nan nan | Khan and Apkarian (10) studied the differences between cyclic and noncyclic pain using standardized pain questionnaires, including the McGill Pain instrument in 271 women, and found that the level of pain described by the subjects was equivalent to chronic cancer pain, and just less than the pain of rheumatoid arthritis. They noted that women with cyclic pain tended to refer to heaviness and tenderness as found in the Preece study, whereas women with noncyclic pain related the severity to the area of breast involved. | 6 | 0.005 | 0.098 | 0.063 | 0.042 | 0.087 | 0.007 | 0.098 | 2 |
205 | Management of Disorders of the Ductal System and Infections | EVALUATION | null | nan nan | Important aspects of history-taking include the type of pain, relationship to menses, duration, location, and any other medical problems. The impact of the pain on the everyday activities of the patient, particularly sleep and work, should be established to assess the need for medication. | 6 | 0.05 | 0.09 | 0.08 | 0.07 | 0.06 | 0.01 | 0.09 | 2 |
206 | Management of Disorders of the Ductal System and Infections | EVALUATION | null | nan nan | After inspection, the first aspect of the breast examina- tion should be very gentle palpation of the breasts once the patient has indicated the site(s) of the pain. Having excluded discrete masses, a more probing evaluation should be performed, focusing on the site(s) of pain. After turning the patient half on her side so that the breast tissue falls away from the chest wall, it may be possible to identify that the pain is arising from the underlying rib or costal car- tilage. The pain can be reproduced by placing a fingertip on the affected rib and demonstrating to the patient its source. Nodularity can be associated with mastalgia, but the extent is unrelated to pain severity; in younger women, the finding is so common that it should be considered within the spectrum of normality. If it is apparent that the pain, whether cyclic or noncyclic, is mammary in origin, the decision to treat is based on the subjective assessment of severity, together with the duration of symptoms. This assessment may be facilitated by a daily pain chart that assesses the timing and severity (semiquantitative scale) of the pain. Generally, there should be a history of pain of at | 6 | 0.05 | 0.09 | 0.08 | 0.07 | 0.06 | 0.01 | 0.09 | 2 |
207 | Management of Disorders of the Ductal System and Infections | EVALUATION | null | nan nan | least 4 months before hormonal therapy is indicated. | 6 | 0.025 | 0.016 | 0.038 | 0.079 | 0.044 | 0.025 | 0.079 | 4 |
208 | Management of Disorders of the Ductal System and Infections | ROLE OF RADIOLOGY | null | nan nan | The average age of women entered into trials of treatment for mastalgia is 32 years: In this age group, mammogra- phy is not a standard adjunct to clinical evaluation. In the absence of a discrete lump, ultrasonography is also | 6 | 0.01 | 0.095 | 0.08 | 0.07 | 0.06 | 0.04 | 0.095 | 2 |
209 | Management of Disorders of the Ductal System and Infections | ROLE OF RADIOLOGY | null | nan nan | unlikely to give useful information, but any breast lump present requires triple assessment. No specific mammo- gram findings are associated with breast pain. | 6 | 0 | 0.015 | 0.02 | 0.03 | 0.04 | 0.006 | 0.04 | 5 |
210 | Management of Disorders of the Ductal System and Infections | ROLE OF RADIOLOGY | null | nan nan | Ultrasonography in 212 asymptomatic women and 212 with mastalgia showed the mean maximal duct dilatation was 1.8 mm in normal women compared with 2.34 mm in the 136 with cyclic pain and 3.89 mm in the 76 with non- cyclic pain. Dilated ducts were found in all quadrants, but mostly in the retroareolar area, and dilatation did not alter during the menstrual cycle. A highly significant association was found between the extent of ductal dilatation and pain severity. | 6 | 0 | 0.05 | 0 | 0 | 0.05 | 0 | 0.05 | 2 |
211 | Management of Disorders of the Ductal System and Infections | ROLE OF RADIOLOGY | null | nan nan | The meaning of these findings are unclear as no relation- ship was shown in the cyclic pain patients with the consid- erable temporal symptoms in this group, but the noncyclic group could be explained by the periductal inflammation often seen in this group. | 6 | 0.01 | 0.095 | 0.08 | 0.07 | 0.06 | 0.04 | 0.095 | 2 |
212 | Management of Disorders of the Ductal System and Infections | MONDOR’S DISEASE | null | nan nan | Mondor’s disease is a rare cause of breast pain, with diag- nostic clinical features of local pain associated with a ten- der, palpable subcutaneous cord or linear skin dimpling. The cause is superficial thrombophlebitis of the lateral tho- racic vein or a tributary. The condition resolves spontane- ously. Mondor’s disease can cause serious alarm because some patients assume that the skin tethering is secondary to an underlying carcinoma, so they are greatly relieved when informed of the benign nature of the condition. | 6 | 0.01 | 0.095 | 0.08 | 0.07 | 0.06 | 0.04 | 0.095 | 2 |
213 | Management of Disorders of the Ductal System and Infections | MONDOR’S DISEASE | null | nan nan | In a series of 63 cases of Mondor’s disease, no underly- ing pathologic process was found in 31 cases. Of the remain- ing 32, local trauma or surgical intervention was responsible in 15 (47%), an inflammatory process in 6 (19%), and carci- noma in 8 (25%). In view of this, mammography should be performed in women with Mondor’s disease who are aged 35 years or older to exclude an impalpable breast cancer. | 6 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 |
214 | Management of Disorders of the Ductal System and Infections | PSYCHOSOCIAL ASPECTS | null | nan nan | Several studies have confirmed that patients with severe mastalgia have psychological morbidity that may be the result rather than the cause of their breast pain. Preece et al. (11) used the Middlesex Hospital Questionnaire to compare patients with mastalgia, psychiatric patients, and minor surgical cases. No significant differences were found between the patients with breast pain and the surgical cases, and both scored significantly lower than psychiat- ric cases. Only the scores of patients who failed treatment approached those of psychiatric patients. In a small study of 25 women with severe mastalgia, using the Composite International Diagnostic Interview, 45 diagnoses were made in 21 patients (84%): anxiety (n = 17), panic disorder (n = 5), somatization disorder (n = 7), and major depression (n = 16). | 6 | 0.09 | 0.09 | 0.08 | 0.09 | 0.09 | 0.09 | 0.09 | 1 |
215 | Management of Disorders of the Ductal System and Infections | PSYCHOSOCIAL ASPECTS | null | nan nan | A study using the Hospital Anxiety and Depression Scale (HADS) reported high levels of both anxiety and depression in 20 women with severe mastalgia. At Guy’s Hospital, HADS was also used to evaluate 54 patients with mastalgia (12). The 33 women with severe pain manifested levels of anxiety and depression comparable with those in women with breast cancer before surgery. Those who responded to treatment had a significant improvement in psychosocial function, but the nonresponders continued to have high levels of distress. Fox et al. (13) conducted a prospective trial in 45 women with mastalgia who kept pain diaries for 12 weeks, with half randomized to listen daily to a relaxation tape during weeks | 6 | 0.098 | 0.076 | 0.089 | 0.095 | 0.092 | 0.095 | 0.098 | 1 |
216 | Management of Disorders of the Ductal System and Infections | PSYCHOSOCIAL ASPECTS | null | nan nan | 5 to 8. Abnormal or borderline HADS scores were found at entry in 54%, and a complete or substantial reduction in pain score was measured in 25% of the control subjects and 61% of those randomized to relaxation therapy (p < .005). | 6 | 0.9 | 0.7 | 0.3 | 0.8 | 0.9 | 0.9 | 0.9 | 1 |
217 | Management of Disorders of the Ductal System and Infections | MASTALGIA AND BREAST CANCER RISK | null | nan nan | Because of the lack of precision in classification of benign breast conditions in older studies, it was difficult to deter- mine whether breast pain led to an increased risk of subse- quent breast cancer. Foote and Stewart wrote in 1945, “Any point of view that one chooses to take concerning the rela- tion of so-called cystic mastitis to mammary cancer can be abundantly supported from the literature.” | 6 | 0.02 | 0.03 | 0.06 | 0.07 | 0.08 | 0.09 | 0.09 | 6 |
218 | Management of Disorders of the Ductal System and Infections | MASTALGIA AND BREAST CANCER RISK | null | nan nan | Webber and Boyd carried out a critical analysis of the 36 published papers that were available in English before 1984. They set 16 standards, including a description of the study population, a definition of benign disease, follow-up, and a description of the risk analysis. Of the 22 studies reporting an increase in risk, all met more of the standards than the 11 sug- gesting no increase in risk and the 3 drawing no conclusions. Since then, a few studies have specifically examined the relation between cyclic mastalgia and breast cancer risk. A French case-control study among premenopausal women— 210 younger than 45 years of age with breast cancer, and 210 neighborhood control subjects—matched on year of birth, education level, and age at first full-term pregnancy gave an unadjusted relative risk (RR) for cancer in cyclic mastalgia of 2.66, and after adjustment for family history, prior benign breast disease, and age at menarche, the RR was still signifi- | 6 | 0.07 | 0.08 | 0.09 | 0.1 | 0.09 | 0.08 | 0.1 | 4 |
219 | Management of Disorders of the Ductal System and Infections | MASTALGIA AND BREAST CANCER RISK | null | nan nan | cantly elevated at 2.12. | 6 | 0.09 | 0.085 | 0.075 | 0.065 | 0.045 | 0.035 | 0.09 | 1 |
220 | Management of Disorders of the Ductal System and Infections | MASTALGIA AND BREAST CANCER RISK | null | nan nan | Goodwin et al. (14) recruited 192 women with premeno- pausal node-negative breast cancer and 192 age-matched premenopausal control subjects. Significant risk variables for breast cancer in the model were marital status, family history, number of years of smoking, prior breast biopsy (before cancer diagnosis), and mean cyclic change in breast tenderness. The odds ratio of cancer for cyclic mastalgia was 1.35, rising to 3.32 in those with severe pain. | 6 | 0.06 | 0.08 | 0.07 | 0.09 | 0.08 | 0.07 | 0.09 | 4 |
221 | Management of Disorders of the Ductal System and Infections | MASTALGIA AND BREAST CANCER RISK | null | nan nan | Another indication of a possible link between mastalgia and cancer is the relationship between Wolfe grade of mam- mograms and breast pain. Deschamps et al. (15) determined the Wolfe grades of 1,394 women in the Canadian National Breast Screening Study. All completed a questionnaire, with mastalgia reported by 46%. The extent of dysplasia on mam- mograms was categorized as Dy2 (25% to 49%), Dy3 (50% to 74%), and Dy4 (75%). The odds ratio for a Dy3/4 rating was | 6 | 0.08 | 0.09 | 0.07 | 0.08 | 0.08 | 0.08 | 0.09 | 2 |
222 | Management of Disorders of the Ductal System and Infections | MASTALGIA AND BREAST CANCER RISK | null | nan nan | 1.0 for those who never had breast swelling and mastalgia, whereas it was 2.7 in those reporting both symptoms. | 6 | 0.095 | 0.086 | 0.093 | 0.094 | 0.092 | 0.091 | 0.095 | 1 |
223 | Management of Disorders of the Ductal System and Infections | MASTALGIA AND BREAST CANCER RISK | null | nan nan | These epidemiologic studies have the problems of recall biases and unknown extent of histologic atypia in the patients who have not had biopsies. In most studies assess- ing risk using established algorithms, the presence of breast pain is not used as an independent variable in the calcula- tions, unlike prior breast biopsy. That women attend a phy- sician for breast pain, itself results in a higher rate of breast biopsy as noted in the study by Ader et al. (3). | 6 | 0.05 | 0.01 | 0.02 | 0.01 | 0.04 | 0.01 | 0.05 | 1 |
224 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | Several agents have been found in controlled trials to be no better than placebo: vitamin E, lynestrenol, mefenamic acid, and caffeine reduction. This is perhaps not surprising because placebo-controlled trials report placebo response rates from 10% to 50%. | 6 | 0.02 | 0.03 | 0.04 | 0.06 | 0.07 | 0.08 | 0.08 | 6 |
225 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | As an alternative, more complex approach, reduction in dietary fat can significantly reduce cyclic breast pain. Boyd et al. (17) entered 21 women with a minimum of 5 years of breast pain into a trial in which 11 were shown how to reduce their dietary fat content to 15% of total calories and 10 received general dietary advice. Those in the fat- reduction group had a significant reduction in breast pain. Although a nondrug intervention appeals to many patients, long-term dietary change is a difficult intervention to main- tain in premenopausal women with busy lives. | 6 | 0.098 | 0.063 | 0.042 | 0.088 | 0.088 | 0.088 | 0.098 | 1 |
226 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | A similar dietary approach of adding the long-chain unsaturated fatty acid gamma-linolenic acid, present in eve- ning primrose oil and starflower oil, provides a nonendo- crine approach, but with an efficacy that is questionable. One study entered 103 women with mastalgia into a double- blinded, crossover study comparing evening primrose oil with placebo for 3 months, after which both groups received evening primrose oil capsules for a further 3 months. Cyclic pain was significantly diminished in those given evening primrose oil, but had no effect on noncyclic mastalgia. | 6 | 0.005 | 0.02 | 0.04 | 0.07 | 0.08 | 0.09 | 0.09 | 6 |
227 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | However, a systematic literature search by Budeiri to determine the efficacy of evening primrose oil for premen- strual syndrome found no evidence of benefit (18). A more recent Dutch trial also failed to show an advantage for eve- ning primrose oil (19). | 6 | 0.05 | 0.075 | 0.025 | 0.06 | 0.03 | 0.04 | 0.075 | 2 |
228 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | In an attempt to resolve this question, one of the larg- est studies ever performed in both community and hos- pital patients involving a total of 555 patients was carried out, but with a different placebo arm to the previous trials. This trial failed to show any advantage of the active arms containing gamma-linoleic acid, principally owing to the very large response of 40% reduction in symptoms in the placebo group (20). Despite this, many physicians advise their patients to try this product, which is widely available in nonprescription format, as an initial treatment of breast pain because the incidence of side effects was very low in all the trials. In practical terms it is likely that the patients feel better due to the large placebo effect. | 6 | 0.01 | 0.03 | 0.06 | 0.08 | 0.09 | 0.07 | 0.09 | 5 |
229 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | In cyclic mastalgia, most treatments have focused on reduction in estrogen or prolactin drive to the breast cells in the belief that hormonal overstimulation is the predominant | 6 | 0.09 | 0.085 | 0.075 | 0.065 | 0.1 | 0.095 | 0.1 | 5 |
230 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | factor in severe breast pain, although as noted above little evidence exists for this hypothesis. | 6 | 0.015 | 0.023 | 0.047 | 0.068 | 0.092 | 0.089 | 0.092 | 5 |
231 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | Danazol, an impeded androgen, may relieve pain in up to 93% of patients, but with side effects that include nausea, depression, menstrual irregularity, and headaches in up to two-thirds of patients, sometimes leading to discontinuation of treatment. To reduce side effects, O’Brien and Abukhali | 6 | 0.05 | 0.075 | 0.08 | 0.1 | 0.06 | 0.04 | 0.1 | 4 |
232 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | (21) conducted a double-blinded, placebo-controlled trial of luteal-phase danazol in 100 women with premenstrual syn- drome, including cyclic mastalgia. Danazol or placebo was given during the luteal phase for three cycles, with a signifi- cant pain reduction in those treated and similar side effects in both groups. | 6 | 0.095 | 0.087 | 0.063 | 0.042 | 0.036 | 0.021 | 0.095 | 1 |
233 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | As an alternative to drugs, some physicians recommend a more supportive brassiere to relieve mastalgia. In a non- randomized study of 200 Saudi women with mastalgia, 100 were given danazol 200 mg/day and 100 instructed to wear a sports brassiere. Pain was relieved in 85% of those who wore sports brassieres and in 58% of those given danazol, but of the latter group 42% had side effects and 15% stopped treatment. The results of this trial are difficult to interpret due to its nonblinded, nonrandomized structure. | 6 | 0.3 | 0.6 | 0.9 | 0.7 | 0.1 | 0.1 | 0.9 | 3 |
234 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | The efficacy of progesterone vaginal cream has been investigated in two small randomized trials. In a small study, McFadyen reported a minor, nonsignificant benefit for those women given placebo cream. In a larger trial with 80 participants, a greater than 50% reduction in pain was recorded in 22% of the placebo group and in 65% of those given progesterone-containing cream. | 6 | 0.1 | 0.3 | 0.4 | 0.2 | 0.3 | 0.2 | 0.4 | 3 |
235 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | Tamoxifen, a partial estrogen antagonist and agonist, is effective in treating breast pain. In the first double-blinded, crossover, randomized trial, conducted at Guy’s Hospital, pain relief occurred in 71% of those given tamoxifen and 38% of control subjects (24). After 3 months, nonresponders switched to the alternative treatment arm, and pain control was achieved in 75% of the tamoxifen group and 33% of the placebo group. The most common side effect of tamoxifen was hot flashes, occurring in 27%. | 6 | 0.09 | 0.06 | 0.08 | 0.07 | 0.05 | 0.04 | 0.09 | 1 |
236 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | tamoxifen 10 mg with 20 mg, similar response rates were seen but side effects with the lower dose were substantially reduced (21% vs. 64%). When tamoxifen was compared with danazol, similar response rates were seen, but significantly more side effects occurred in those given danazol (90% vs. 50%). When tamoxifen 10 mg was compared with bromocrip- tine 7.5 mg daily, pain relief was achieved in 18 of 20 (90%) of the tamoxifen group and in 17 of 20 (85%) of those given bromocriptine. Tamoxifen is now being used extensively in the management of breast pain, as an off-label drug because it is not currently licensed for use in benign breast conditions. The safety of this drug in patients without breast cancer is, however, well documented in the prevention trials involving large numbers of normal high-risk women (25). Furthermore, this review of the prevention trials confirms the reduction in benign breast conditions on the drug, which is consistent with the reduction in symptoms seen in the breast pain tri- als. Patients who are prescribed tamoxifen should be given a careful explanation that the drug is being used to reduce estrogen drive and is not being used for breast cancer. | 6 | 0.03 | 0.05 | 0.07 | 0.08 | 0.09 | 0.01 | 0.09 | 5 |
237 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | Alternative routes of delivery of tamoxifen or selective estrogen receptor modulators (SERMS) may be possible by the transcutaneous route to reduce side effects by avoiding transhepatic passage. This approach has shown some prom- ise using a gel containing 4-hydroxy tamoxifen applied to the breast morning and night (26). A placebo-controlled trial of this gel showed efficacy in cyclic mastalgia, particularly in the late luteal phase of the cycle, and showed a clear blunting of the luteal peak of cyclic breast pain (Fig. 6-1). It is clear that these series of studies of SERMS and the prevention studies | 6 | 0.09 | 0.085 | 0.075 | 0.08 | 0.085 | 0.095 | 0.095 | 6 |
238 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | confirm the active therapeutic role of these agents in benign conditions of the breast. These new agents are currently not licensed in the treatment of breast pain, and are awaiting fur- ther safety data as it is a novel formulation of tamoxifen. | 6 | 0.09 | 0.085 | 0.075 | 0.065 | 0.1 | 0.095 | 0.1 | 5 |
239 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | A recent randomized study compared a novel anties- trogen ormeloxifine with danazol and showed that the new agent, which has predominantly antagonist actions, was as effective as danazol but with fewer side effects (27). Pain was assessed by VAS pain scores and ormeloxifine (Centchroman) produced a reduction in median pain scores from 7 at baseline to 2 at 12 weeks. | 6 | 0.09 | 0.085 | 0.06 | 0.04 | 0.03 | 0.02 | 0.09 | 1 |
240 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | The relationship of the menstrual cycle in cyclic breast pain was further demonstrated by a randomized trial of the luteinizing hormone-releasing hormone (LHRH) agonist gos- erelin (Zoladex), which abolishes the menstrual cycle and thus removes the normal fluctuation in estradiol and pro- gesterone. This large placebo-controlled trial of women with cyclic mastalgia treated with Zoladex for 6 months showed significant reduction in breast pain (28). The patients were then followed off treatment for 6 months and the breast pain gradually returned as did menstruation. | 6 | 0.05 | 0.1 | 0.075 | 0.09 | 0.1 | 0.1 | 0.1 | 2 |
241 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | In a different approach, Ingram et al. (29) studied iso- flavones derived from red clover to determine whether this phytoestrogen could relieve mastalgia. The 18 patients in the trial underwent a 2-month, single-blinded, placebo run-in phase, after which they received either pla- cebo, isoflavone 40 mg, or isoflavone 80 mg. Pain scores for the final single-blinded month and the final double-blinded month were compared. In the placebo group, there was a 13% reduction, for the 40 mg/day group it was 44%, and for | 6 | 0.5 | 0.75 | 0.6 | 0.5 | 0.5 | 0.5 | 0.75 | 2 |
242 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | 100 | 6 | 0.05 | 0.09 | 0.08 | 0.07 | 0.06 | 0.04 | 0.09 | 2 |
243 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | 60 | 6 | 0.05 | 0.09 | 0.08 | 0.07 | 0.01 | 0.02 | 0.09 | 2 |
244 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | 40 | 6 | 0.05 | 0.09 | 0.08 | 0.07 | 0.06 | 0.01 | 0.09 | 2 |
245 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | 30 | 6 | 0.005 | 0.01 | 0.02 | 0.04 | 0.06 | 0.07 | 0.07 | 6 |
246 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | 20 | 6 | 0.005 | 0.01 | 0.03 | 0.04 | 0.08 | 0.09 | 0.09 | 6 |
247 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | 0 | 6 | 0.1 | 0.95 | 0.8 | 0.7 | 0.6 | 0.45 | 0.95 | 2 |
248 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | 0 10 | 6 | 0.25 | 0.3 | 0.4 | 0.6 | 0.7 | 0.8 | 0.8 | 6 |
249 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | 20 30 0 10 20 30 0 10 20 30 | 6 | 0.5 | 0.4 | 0.6 | 0.7 | 0.8 | 0.9 | 0.9 | 6 |
250 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | Cycle 1 | 6 | 0.09 | 0.085 | 0.075 | 0.065 | 0.055 | 0.045 | 0.09 | 1 |
251 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | Cycle 2 | 6 | 0.09 | 0.085 | 0.075 | 0.065 | 0.1 | 0.095 | 0.1 | 5 |
252 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | Day of Cycle | 6 | 0.025 | 0.037 | 0.041 | 0.068 | 0.059 | 0.041 | 0.068 | 4 |
253 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | Cycle 4 | 6 | 0.09 | 0.085 | 0.075 | 0.065 | 0.1 | 0.095 | 0.1 | 5 |
254 | Management of Disorders of the Ductal System and Infections | TREATMENT TRIALS | null | nan nan | FIGURE 6-1 Effect of topical 4-hydroxy tamoxifen gel on cyclical mastalgia. Randomized trial of 4-hydroxy tamoxifen gel (2 and 4 mg vs. placebo gel) applied to the breast for breast pain. Note the clear cyclical pattern of pain and the reduction of the peak luteal pain in cycle 4 by the 4-mg preparation. (From Mansel R, Goyal A, Nestour EL, et al. and the Afimoxifene [4-OHT] Breast Pain Research Group. A phase II trial of Afimoxifene [4-hydroxytamoxifen gel] for cyclical mastalgia in premenopausal women. Breast Cancer Res Treat 2007;106[3]:389–397, with permission.) | 6 | 0.005 | 0.01 | 0.01 | 0.01 | 0.01 | 0.01 | 0.01 | 2 |
255 | Management of Disorders of the Ductal System and Infections | ALTERNATIVE APPROACHES | null | nan nan | Acupuncture has been used for the treatment of premen- strual syndrome with some improvement of symptoms, but a recent study from the Mayo Clinic showed that pain scores measured on a 10-point brief inventory scale showed a clini- cally meaningful improvement in 67% of patients with the worst pain (30). The authors have suggested a randomized trial is required to confirm the findings, but this would be dif- ficult to blind from the patient and placebo responses would be difficult to evaluate. At Guy’s Hospital in an open pilot study, applied kinesiology was used in 88 women with self- rated moderate or severe mastalgia present for more than 6 months. This technique uses a type of pressure massage and is a hands-on technique based on improving lymphatic flow. Using self-rated pain scores, there was improvement in 60% and complete resolution in 18%, but as with the acu- puncture trials, this trial was not blinded, and the response may have been due to placebo effects. | 6 | 0.095 | 0.092 | 0.094 | 0.093 | 0.092 | 0.091 | 0.095 | 1 |
256 | Management of Disorders of the Ductal System and Infections | ALTERNATIVE APPROACHES | null | nan nan | A randomized trial of Vitus agnus-castus extract (castor oil, Mastodynon) showed a modest fall in VAS scores on the plant extract (54% compared with 40% on placebo), with few side effects (Mastodynon). | 6 | 0.1 | 0.2 | 0.3 | 0.4 | 0.5 | 0.6 | 0.6 | 6 |
257 | Management of Disorders of the Ductal System and Infections | ALTERNATIVE APPROACHES | null | nan nan | Ghent et al. (31) investigated the effect of iodine replace- ment in women with breast pain in three different studies, one of which was a randomized, double-blinded, placebo- controlled trial. The rationale was that iodine deficiency in Sprague-Dawley rats led to mammary epithelial hyperplasia and carcinoma. Participants were treated for 6 months with aqueous molecular iodine 0.07 to 0.09 mg/kg daily, or pla- cebo composed of an aqueous mixture of brown vegetable dye and quinine. Pain improvement occurred in 11 of 33 (33%) of the placebo group and 15 of 23 (65%) of those given iodine. No side effects were reported. More recently Kessler | 6 | 0.08 | 0.04 | 0.06 | 0.07 | 0.08 | 0.09 | 0.09 | 6 |
258 | Management of Disorders of the Ductal System and Infections | ALTERNATIVE APPROACHES | null | nan nan | (32) studied supraphysiologic doses of iodine in cyclic mastalgia and reported that approximately 40% of patients obtained more than 50% reduction in breast pain on 3 to 6 mg iodine daily compared with 8% on placebo. | 6 | 0.1 | 0.1 | 0.1 | 0.1 | 0.1 | 0.1 | 0.1 | 1 |
259 | Management of Disorders of the Ductal System and Infections | EXTRA MAMMARY PAIN | null | nan nan | 1.12 placebo, p < .001) (33). | 6 | 0.095 | 0.087 | 0.064 | 0.087 | 0.095 | 0.095 | 0.095 | 1 |
260 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | without careful selection, surgical intervention will damage body image without achieving pain relief. Even after careful psychiatric assessment, excisional surgery should very rarely be undertaken because clinical experience has shown that pain reduction is achieved in only a small number of patients. This is not surprising because the etiology of breast pain is poorly understood, and there are causes of pain that lie out- side the breast tissue. In the author’s experience the focus on pain will often move to body image after mastectomy and this leaves an unhappy patient who still complains of breast pain, which is clearly therapeutic failure. | 6 | 0 | 0.015 | 0.02 | 0.03 | 0.04 | 0.06 | 0.06 | 6 |
261 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | A recent overview has considered the role of drugs in the treatment of mastalgia. Srivastava et al. considered the range of drugs available but concluded that the only effec- tive drugs were tamoxifen, bromocriptine, and danazol | 6 | 0.05 | 0.1 | 0.075 | 0.09 | 0.08 | 0.06 | 0.1 | 2 |
262 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | The precise mechanisms behind many of the symptom- atic presentations of benign breast change remain unclear, but the various hypotheses have been summarized in a review by Santen and Mansel (35). | 6 | 0.09 | 0.08 | 0.07 | 0.06 | 0.01 | 0.02 | 0.09 | 1 |
263 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | MANAGEMENT SUMMARY | 6 | 0.05 | 0.09 | 0.08 | 0.07 | 0.06 | 0.01 | 0.09 | 2 |
264 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Crandall CJ, Aragaki AK, Cauley JA, et al. Breast tenderness and breast cancer risk in the estrogen plus progestin and estrogen-alone women’s health initiative clinical trials. Breast Cancer Res Treat 2012;132:275–285. | 6 | 0.09 | 0.06 | 0.04 | 0.08 | 0.07 | 0.09 | 0.09 | 1 |
265 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Barros AC, Mottola J, Ruiz CA, et al. Reassurance in the treatment of mas- talgia. Breast J 1999;5:162. | 6 | 0 | 0 | 0 | 0 | 0.083 | 0 | 0.083 | 5 |
266 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Ader DN, South-Paul J, Adera T, et al. Cyclical mastalgia: prevalence and associated health behavioural factors. J Psychosom Obstet Gynaecol 2001;22:71–76. | 6 | 0.005 | 0.09 | 0.08 | 0.04 | 0.03 | 0.005 | 0.09 | 2 |
267 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Ader DN, Browne MW. Prevalence and impact of cyclical mastalgia in a United States clinic-based sample. Am J Obstet Gynecol 1997;177:126–132. | 6 | 0 | 0.05 | 0 | 0 | 0.05 | 0 | 0.05 | 2 |
268 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Wang DY, Fentiman IS. Epidemiology and endocrinology of benign breast disease. Breast Cancer Res Treat 1985;6:5. | 6 | 0.023 | 0.047 | 0.023 | 0.023 | 0.023 | 0.047 | 0.047 | 2 |
269 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Hughes LE, Mansel RE, Webster DJT. Aberrations of normal development and involution (ANDI): a new perspective on pathogenesis and nomencla- ture of benign breast disorders. Lancet 1987;2:1316. | 6 | 0 | 0.05 | 0 | 0 | 0.05 | 0 | 0.05 | 2 |
270 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Ecochard R, Marret H, Rabilloud M, et al. Gonadotropin level abnormali- ties in women with cyclic mastalgia. Eur J Obstet Gynecol 2001;94:92. | 6 | 0.005 | 0.08 | 0.07 | 0.06 | 0.03 | 0.01 | 0.08 | 2 |
271 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Lancet 1976;2:670. | 6 | 0.005 | 0.03 | 0.04 | 0.08 | 0.01 | 0.02 | 0.08 | 4 |
272 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Preece PE, Mansel RE, Hughes LE. Mastalgia: psychoneurosis or organic disease? BMJ 1978;1:29. | 6 | 0 | 0.05 | 0 | 0 | 0.05 | 0 | 0.05 | 2 |
273 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Ramirez AJ, Jarrett SR, Hamed H, et al. Psychological adjustment of women with mastalgia. Breast 1995;4:48. | 6 | 0 | 0.02 | 0.03 | 0.06 | 0.07 | 0.08 | 0.08 | 6 |
274 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Fox H, Walker LG, Heys SD, et al. Are patients with mastalgia anxious, and does relaxation help? Breast 1997;6:138. | 6 | 0.05 | 0.02 | 0.04 | 0.01 | 0.03 | 0.02 | 0.05 | 1 |
275 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Goodwin PJ, DeBoer G, Clark RM, et al. Cyclical mastopathy and premeno- pausal breast cancer risk. Breast Cancer Res Treat 1994;33:63. | 6 | 0.025 | 0.075 | 0.05 | 0.08 | 0.05 | 0.05 | 0.08 | 4 |
276 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Deschamps M, Band PR, Coldman AJ, et al. Clinical determinants of mam- mographic dysplasia patterns. Cancer Detect Prev 1996;20:610. | 6 | 0.005 | 0.03 | 0.04 | 0.07 | 0.08 | 0.09 | 0.09 | 6 |
277 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Kumar S, Rai R, Das V, et al. Visual analogue scale for assessing breast nodularity in non-discrete lumpy breasts: the Lucknow-Cardiff breast nodularity scale. Breast 2010;19:238–242. | 6 | 0.005 | 0.07 | 0.06 | 0.08 | 0.09 | 0.09 | 0.09 | 5 |
278 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Boyd NF, Shannon P, Kriukov V, et al. Effect of a low-fat high-carbohydrate diet on symptoms of cyclical mastopathy. Lancet 1988;2:128. | 6 | 0 | 0.05 | 0 | 0 | 0.05 | 0 | 0.05 | 2 |
279 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Goyal A, Mansel RE. A randomized multicentre study of gamolenic acid (Efamast) with and without antioxidant vitamins and minerals in the man- agement of mastalgia. Breast J 2005;11:41–47. | 6 | 0.098 | 0.096 | 0.093 | 0.095 | 0.097 | 0.095 | 0.098 | 1 |
280 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Mansel RE, Dogliotti L. European multicentre trial of bromocriptine in cyclical mastalgia. Lancet 1990;335:190. | 6 | 0.2 | 0.4 | 0.3 | 0.2 | 0.3 | 0.2 | 0.4 | 2 |
281 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Fentiman IS, Caleffi M, Brame K, et al. Double-blind controlled trial of tamoxifen therapy for mastalgia. Lancet 1986;1:287. | 6 | 0.05 | 0.03 | 0.04 | 0.02 | 0.01 | 0.02 | 0.05 | 1 |
282 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Cuzick J, Powles T, Veronesi U, et al. Overview of the main outcomes in breast-cancer prevention trials. Lancet 2003;361:296–230. | 6 | 0.005 | 0.08 | 0.07 | 0.04 | 0.08 | 0.08 | 0.08 | 2 |
283 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Mansel RE, Goyal A, Nestour EL, et al. and Afimoxifine (4-OHT) Breast Pain Research Group. A phase II trial of Afimoxifime (4-hydroxytamoxifen gel) for cyclical mastalgia in premenopausal women. Breast Cancer Res Treat 2007;106(3):389–397. | 6 | 0.005 | 0.01 | 0.01 | 0.01 | 0.01 | 0.01 | 0.01 | 2 |
284 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Tejwani PC, Srivastava A, Nerker H, et al. Centchroman regresses mas- talgia: a randomized comparison with danazol. Indian J Surg 2011;73: 199–205. | 6 | 0.08 | 0.06 | 0.04 | 0.08 | 0.08 | 0.08 | 0.08 | 1 |
285 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Mansel RE, Goyal A, Preece P, et al. European randomized, multicenter study of goserelin (Zoladex) in the management of mastalgia. Am J Obstet Gynecol 2004;191:1942–1949. | 6 | 0.005 | 0.03 | 0.06 | 0.07 | 0.08 | 0.09 | 0.09 | 6 |
286 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Ingram DI, Hickling C, West L, et al. A double-blind randomized con- trolled trial of isoflavones in the treatment of cyclical mastalgia. Breast 2002;11:170. | 6 | 0.095 | 0.08 | 0.06 | 0.04 | 0.03 | 0.02 | 0.095 | 1 |
287 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Thicke LA, Hazelton JK, Bauer BA, et al. Acupuncture for treatment of noncyclic breast pain: a pilot study. Am J China Med 2011;39:117–129. | 6 | 0.005 | 0.08 | 0.06 | 0.04 | 0.01 | 0.02 | 0.08 | 2 |
288 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Ghent WR, Eskin BA, Low DA, et al. Iodine replacement in fibrocystic dis- eases of the breast. Can J Surg 1993;36:453. | 6 | 0.02 | 0.07 | 0.08 | 0.09 | 0.05 | 0.06 | 0.09 | 4 |
289 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Kessler KH. The effect of supraphysiological levels of iodine on patients with cyclic mastalgia. Breast J 2004;10:328–336. | 6 | 0.005 | 0.09 | 0.07 | 0.08 | 0.08 | 0.09 | 0.09 | 2 |
290 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Colak T, Ipek T, Kanik A, et al. Efficacy of topical nonsteroidal anti-inflam- matory drugs in mastalgia treatment. J Am Coll Surg 2003;196:525–530. | 6 | 0.08 | 0.07 | 0.04 | 0.08 | 0.08 | 0.08 | 0.08 | 1 |
291 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Srivastava A, Mansel RE, Arvind N, et al. Evidence based management of mastalgia: a meta-analysis of randomized trials. Breast 2007;16: 503–512. | 6 | 0.098 | 0.094 | 0.095 | 0.095 | 0.095 | 0.095 | 0.098 | 1 |
292 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Santen RJ, Mansel R. Benign breast disorders. N Engl J Med 2005;353: 275–285. | 6 | 0.1 | 0.1 | 0.1 | 0.1 | 0.1 | 0.1 | 0.1 | 1 |
293 | Management of Disorders of the Ductal System and Infections | ROLE OF SURGERY | null | nan nan | Breast disease during pregnancy and lactation can represent a clinical and diagnostic dilemma for the clinician due to the significant change to the breast parenchyma from hor- mone-related hypertrophy and increased vascularity. These changes affect the clinical breast examination as well as alter the efficacy of the currently available imaging modali- ties. Added to this is the need to balance concern for the mother with concern for the fetus. Breast cancer remains one of the most common types of cancer to be diagnosed during pregnancy or in the lactational period (1) (see Chapter 67); benign breast disease, however, is even more prevalent during this period. It is critical for the physician to remain as diligent in the evaluation of any breast abnor- mality in the pregnant or lactating patient as one would in any other woman. This chapter reviews the current state of the diagnosis and treatment of benign breast disease during pregnancy and lactation. | 6 | 0.05 | 0.08 | 0.09 | 0.02 | 0.03 | 0.04 | 0.09 | 3 |
294 | Management of Disorders of the Ductal System and Infections | EVALUATION | Clinical Breast Examination | nan nan | During the course of pregnancy, pregnancy-related hormones (estrogen, progesterone, and prolactin) cause breast tissue to undergo significant changes that lead to increased vol- ume and density (see Chapter 1). During the first trimester, the ratio of fatty tissue to glandular tissue decreases; as the volume of glandular tissue increases, so does the overall volume of the breast. As the pregnancy progresses, these changes intensify and make the evaluation of any breast abnormality more difficult. It is preferred, therefore, for the pregnant patient to have a baseline clinical breast exami- nation during the first trimester before these changes have occurred. As the number of women who become pregnant during their fourth decade increases, it is likely that more women will present already having had a baseline mammo- gram before becoming pregnant. A prior mammogram and any other imaging study obtained before pregnancy may help facilitate the evaluation of a new mass. | 6 | 0.09 | 0.085 | 0.075 | 0.065 | 0.045 | 0.035 | 0.09 | 1 |
295 | Management of Disorders of the Ductal System and Infections | EVALUATION | Clinical Breast Examination | nan nan | The pregnant patient who presents with a new mass or physical finding should be evaluated and followed very | 6 | 0.015 | 0.023 | 0.047 | 0.068 | 0.092 | 0.087 | 0.092 | 5 |
296 | Management of Disorders of the Ductal System and Infections | EVALUATION | Clinical Breast Examination | nan nan | 58 | 6 | 0.09 | 0.1 | 0.07 | 0.06 | 0.04 | 0.03 | 0.1 | 2 |
297 | Management of Disorders of the Ductal System and Infections | EVALUATION | Clinical Breast Examination | nan nan | closely. If observation is chosen after completion of the appropriate workup (described later in this chapter), a short interval follow-up examination is indicated because delay in examination may allow pregnancy-related changes (such as an increase in volume or nodularity) to obscure the physical finding. Because the pregnant patient does not undergo the cyclic hormonal changes that the non- pregnant patient experiences, persistence of a mass after a short interval warrants further attention (Fig. 7-1). Ultimately, it is the responsibility of the clinician who identifies a breast mass to rule out a pregnancy-associated breast cancer. | 6 | 0.05 | 0.08 | 0.06 | 0.09 | 0.03 | 0.04 | 0.09 | 4 |
298 | Management of Disorders of the Ductal System and Infections | EVALUATION | Diagnostic Imaging Issues in Pregnancy and Lactation | nan nan | When evaluating a pregnant patient, consideration must be given to minimizing exposure of ionizing radiation to the fetus. For this reason, ultrasonography is an ideal first option in the evaluation of a breast mass in this patient pop- ulation. Ultrasound is a reliable means of differentiating a fluid-filled structure (cyst) versus a solid mass. It can assess the margins and shape of a solid mass or identify shadow- ing, which may help differentiate a benign mass (e.g., lymph node or adenoma) from a malignancy. Ultrasound can eas- ily guide aspiration of a cyst or percutaneous biopsy of a suspicious mass. An important benefit of ultrasound is that it is less affected by pregnancy-related changes than is mammography. Ultrasound can have 100% sensitivity for identifying malignancy as seen in multiple studies, and high specificity rates are seen as well (Table 7-1). For these rea- sons, ultrasound is the optimal first imaging study employed for a pregnancy-related breast mass. | 6 | 0.095 | 0.08 | 0.06 | 0.04 | 0.02 | 0.03 | 0.095 | 1 |
299 | Management of Disorders of the Ductal System and Infections | EVALUATION | Diagnostic Imaging Issues in Pregnancy and Lactation | nan nan | FIGURE 7-1 Flow diagram for manage- ment of clinically suspicious breast masses during pregnancy. | 6 | 0.09 | 0.085 | 0.06 | 0.04 | 0.03 | 0.02 | 0.09 | 1 |