16th Chancellor Alfredo T. RamirezMEMORIAL LECTURE
Application of the Management Process in Thyroid Nodules – 30 Years of Experience
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
GreetingsFamily of Dr. Alfredo T. Ramirez
Ms. Bella Yan-RamirezMr. Clark Alfredo Ramirez
GreetingsFoundation for the Advancement of Surgical
Education, Inc.Dr. Telesforo Gana
UPCM-PGH Department of Surgery Dr. Nelson Cabaluna
Postgraduate Courses Committee Dr. Orlino Bisquera
GreetingsSurgical Colleagues
Surgical Learners Friends
Ladies and Gentlemen
Honor
16th Chancellor Alfredo T. Ramirez
Memorial Lecturer
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
For his pioneering spirit in burns, trauma and surgical education
For his leadership inthe field of medical and higher education
For his foresight in developing advances in research and postgraduate surgical training
This memorial lecture is inrecognition of his
dedication, excellence and contribution in Philippine
surgery.PRIVILEGE
For his pioneering spirit in burns, trauma and surgical education
For his leadership inthe field of medical and higher education
For his foresight in developing advances in research and postgraduate surgical training
This memorial lecture is inrecognition of his dedication, excellence and contribution in Philippine surgery.
ROJoson’s grateful memories
to illuminate
ATR’s pioneering spirit, leadership and foresight in higher surgical
education, postgraduate training and
research!
In 1968, ATR started Surgical Forum, research contest for residents.
In 1968, ATR started Surgical Forum, research contest for residents.
I joined it from 1977 to 1979.
Tumors of the Parotid Gland – A Clinicopathologic Study of 139 Cases
Reynaldo O. Joson, MD
Reynaldo O. Joson, MDCarcinoid Tumors of the Gastrointestinal Tract
1977 Surgical Forum
In 1968, ATR started Surgical Forum, research contest for residents.
I joined it from 1977 to 1979.
1978 Surgical Forum
Management of External Gastrointestinal Fistulas
Reynaldo O. Joson, MD
Early Surgery for Appendiceal Abscess Reynaldo O. Joson, MD
In 1968, ATR started Surgical Forum, research contest for residents.
I joined it from 1977 to 1979.
1979 Surgical Forum
Problems and Rehabilitation of Filipino Stoma Patients Reynaldo O. Joson, MD
Thanks to ATR!It gave me great learning opportunity to become a researcher!
In 1968, ATR started Surgical Forum, research contest for residents.
I joined it from 1977 to 1979.
ATR as Chairman of the Department of Surgeryalways encouraged and motivated me to excel in being a medical educator.
Letter of Commendation and Encouragement
UPCM Year Level IV
ATR as Chairman of the Department of Surgeryalways encouraged and motivated me to excel in being a medical educator.
Motivation and Encouragement
Citation
UPCM Year Level V
ATR as Chairman of the Department of Surgeryalways encouraged and motivated me to excel in being a medical educator.
Letter of Commendation and Promotion
Assistant Professor IV(1991)
ATR as Chairman of the Department of Surgeryalways encouraged and motivated me to excel in being a medical educator.
Thanks to ATR!
ATR initiated Master of Science in Clinical Medicine (Surgery) in 1985.
I was the first graduate in 1998.
I was not required to take it.
I gave support because I believe in ATR’s pioneering spirit and foresight in higher surgical education.
Master of Science in Clinical Medicine (Surgery)
ATR initiated Master of Science in Clinical Medicine (Surgery) in 1985.
I was the first graduate in 1998.
I was not required to take it.
I gave support because I believe in ATR’s pioneering spirit and foresight in higher surgical education.
Thanks to ATR!UPCM is the only institution offering MSc in Surgery in the Philippines!
Dr. Carmela LapitanDr. Glenn Genuino
Dr. Mel Anthony Cruz
For his pioneering spirit in burns, trauma and surgical education
For his leadership inthe field of medical and higher education
For his foresight in developing advances in research and postgraduate surgical training
This memorial lecture is inrecognition of his dedication, excellence and contribution in Philippine surgery.
ROJoson’s 3 grateful memories
to illuminate
ATR’s pioneering spirit, leadership and foresight in higher surgical
education, postgraduate training and
research!
Thank you, ATR!
Honor ATR
16th Chancellor Alfredo T. Ramirez Memorial
Lecturer
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Dedication and excellence of ATR in medical education and research!
16th Chancellor Alfredo T. Ramirez
Memorial Lecture
Application of the Management Process in Thyroid Nodules: Thirty Years of
Experience
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
16th Chancellor Alfredo T. Ramirez Memorial Lecture
Application of the Management Process in Thyroid Nodules: Thirty Years
of Experience
52th Postgraduate Course ThemeOncologic Surgery
Current Concepts and Management
16th Chancellor Alfredo T. Ramirez Memorial Lecture
Application of the Management Process in Thyroid Nodules: Thirty
Years of Experience
Former students so impressed with my • usage of patient management process circa 1985• Thyroid Surgical Diseases book 1986
(that’s 30 years ago) which I have been using as a basis in the
management of patients with thyroid disorders / nodules
Pretreatment DiagnosisSpecification of treatment objectives
Management of a Patient Process
PatientMD
GoalsResolution of the Health Problem
Live PatientNo MorbidityNo Disability
Satisfied PatientNo Medico-legal Suit
Interview(symptoms
Physical Exam(signs)
Clinical Diagnostic Processes(pattern recognition / prevalence)
Clinical Diagnosis(primary / secondary)
Advice(health maintenance / disease prevention)
Paraclinical Diagnosis Processes• Indications (degree of certainty/ effect on tx)• Selection (benefit / risk / cost / availability)• Interpretation
Advice
Advice
Advice
Advice
Advice
Selection of Treatment Options(benefit / risk / cost / availability)
Treatment
Pretreatment DiagnosisSpecification of treatment objectives
Management of a Patient Process
PatientMD
GoalsResolution of the Health Problem
Live PatientNo MorbidityNo Disability
Satisfied PatientNo Medico-legal Suit
Interview(symptoms
Physical Exam(signs)
Clinical Diagnostic Processes(pattern recognition / prevalence)
Clinical Diagnosis(primary / secondary)
Advice(health maintenance / disease prevention)
Paraclinical Diagnosis Processes• Indications (degree of certainty/ effect on tx)• Selection (benefit / risk / cost / availability)• Interpretation
Advice
Advice
Advice
Advice
Advice
Selection of Treatment Options(benefit / risk / cost / availability)
Treatment
Presentation Template
Application of the Management Process in Thyroid Nodules – 30 Years of Experience
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Explanation of the Patient Management Processes
Illustration of Application of Processes
MANAGEMENT OF A PATIENT PROCESSPROBLEM-SOLVING AND DECISION-MAKING
UNIVERSAL GOALS
RESOLUTION OF HEALTH PROBLEM
LIVE PATIENTNO COMPLICATIONNO DISABILITYSATISFIED PATIENTNO MEDICOLEGAL SUIT
MANAGEMENT OF A PATIENT PROCESSPROBLEM-SOLVING AND DECISION-MAKING
UNIVERSAL GOALS
RESOLUTION OF HEALTH PROBLEM (THYROID DISORDER)
LIVE PATIENTNO COMPLICATIONNO DISABILITYSATISFIED PATIENTNO MEDICOLEGAL SUIT
Management of a Patient Process
PatientMD
GoalsResolution of the Health Problem
Live PatientNo MorbidityNo Disability
Satisfied PatientNo Medico-legal Suit
Interview(symptoms
Physical Exam(signs)
Clinical Diagnostic Processes(pattern recognition / prevalence)
Clinical Diagnosis(primary / secondary) Advice
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
PROCESSING OF DATA (SIGNS and SYMPTOMS)
PATTERN RECOGNITION (MATCHING)- realization that the patient’s presentationconforms to a previously learned picture or
pattern of disease
PREVALENCE- choice of a diagnosis is based on the frequency of occurrence of the disease in a certain locality, in a certain age and sex group, and in the affected organ and system
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
PROCESSING OF DATA
Knowing the common manifestations of 5 different diseases as follows:
Disease A - abcd (manifestations)Disease B - fghiDisease C - klmnDisease D - pqrsDisease E – uvwx
Given a patient manifesting with pqrs, your diagnosis is Disease D. What is the process used?
Pattern Recognition
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
PROCESSING OF DATA
Knowing the common manifestations of 3 different diseases and relative frequency of each as follows:
Disease A - abcd (manifestations) Least commonDisease B - abcd Disease C - abcd Most common
Given a patient manifesting with abcd, your diagnosis is Disease C.What is/are processes used?
Pattern Recognition but mainly Prevalence
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence
Application in Thyroid Disorders
Majority of the thyroid disorders can be recognized clinically through pattern recognition and prevalence to the point that a clinical diagnosis can be a histopathologic diagnosis.
Common practice by clinicians is to just stop at clinical classification of NNTG; DTG; DNTG; NTG.
GO BEYOND CLINICAL CLASSIFICATION!
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence Application in Thyroid Disorders
Thyroid Pathology in Philippines Can be clinically diagnosed with bases
Diffuse colloid adenomatous goiter √Colloid adenomatous nodule/colloid cyst √
Multiple colloid adenomatous goiter √
Papillary carcinoma √
Follicular carcinoma √
Anaplastic carcinoma √
Medullary carcinoma Difficult unless there is MEN syndrome
Follicular adenoma Difficult
Acute thyroiditis / abscess √
Chronic thyroiditis Difficult
Hyperthyroidism √
Hypothyroidism √
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence Application in Thyroid Disorders
Primary Clinical Diagnosis Signs and Symptoms
Diffuse colloid adenomatous goiter Diffuse goiterPR < 90 / min
No signs of malignancy
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence Application in Thyroid Disorders
Primary Clinical Diagnosis Signs and Symptoms
Colloid adenomatous nodule/colloid cyst Solitary thyroid noduleNot hard, solid / complex / cystic
PR < 90 /minNo signs of malignancy
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence Application in Thyroid Disorders
Primary Clinical Diagnosis Signs and Symptoms
Multiple colloid adenomatous goiter Multiple thyroid nodulesNot hard
PR < 90 / minNo signs of malignancy
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence Application in Thyroid Disorders
Primary Clinical Diagnosis Signs and Symptoms
Papillary carcinoma Solitary thyroid noduleHard solid
PR < 90 / min
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence Application in Thyroid Disorders
Primary Clinical Diagnosis Signs and Symptoms
Papillary carcinoma Solitary thyroid noduleHard solid
No compression (dysphagia, dyspnea)Ipsilateral neck node/s
PR < 90 / min
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence Application in Thyroid Disorders
Primary Clinical Diagnosis Signs and Symptoms
Follicular carcinoma Solitary thyroid noduleLytic bone lesion suspicious of metastasis
No compression (dysphagia, dyspnea)PR < 90 / min
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence Application in Thyroid Disorders
Primary Clinical Diagnosis Signs and Symptoms
Anaplastic carcinoma Huge thyroid mass, fixedNeck compression (dysphagia, dyspnea)
PR < 90 / minElderly
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence Application in Thyroid Disorders
Primary Clinical Diagnosis Signs and Symptoms
Acute thyroiditis / abscess Tender fluctuant thyroid massNo signs of malignancy
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence Application in Thyroid Disorders
Primary Clinical Diagnosis Signs and Symptoms
Chronic thyroiditis Nodular gland with no discrete massPR < 90 / min
No signs of malignancy
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence Application in Thyroid Disorders
Primary Clinical Diagnosis Signs and Symptoms
Hyperthyroidism Diffuse goiterPR > 100/ min
Sudden weight lossWith / without exophthalmos
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence Application in Thyroid Disorders
Primary Clinical Diagnosis Signs and Symptoms
Hypothyroidism Diffuse goiterPR < 90/ min
Short obese stature with unusually slow body movement
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence
Application in Thyroid Disorders
Majority of the thyroid disorders can be recognized clinically through pattern recognition and prevalence to the point that a clinical diagnosis can be a histopathologic diagnosis.
Common practice by clinicians is to just stop at clinical classification of NNTG; DTG; DNTG; NTG.
GO BEYOND CLINICAL CLASSIFICATION!
MANAGEMENT OF A PATIENT PROCESSCLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence
Application in Thyroid Disorders
Rely more on pattern recognition than on prevalence as a priority but use both.
Rely more on physical characteristics of the thyroid lesion than on age and sex.
For further reading:Clinical Diagnosis of Thyroid Disorders – ROJoson - 1985http://www.slideshare.net/rjoson/clinical-diagnosis-of-thyroid-disorders
Thyroid Surgical Diseases - 1986
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process
Pretreatment DiagnosisSpecification of treatment objectives
Management of a Patient Process
PatientMD
GoalsResolution of the Health Problem
Live PatientNo MorbidityNo Disability
Satisfied PatientNo Medico-legal Suit
Interview(symptoms
Physical Exam(signs)
Clinical Diagnostic Processes(pattern recognition / prevalence)
Clinical Diagnosis(primary / secondary)
Paraclinical Diagnosis Processes• Indications (degree of certainty/ effect on tx)• Selection (benefit / risk / cost / availability)• Interpretation
Advice
Advice
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic ProcessIndication - to be more definite on the clinical diagnosis
Selection
Interpretation
Paraclinical Diagnostic Process - Indication
DATA NEEDED
PRIMARY CLINICAL DIAGNOSISSECONDARY CLINICAL DIAGNOSIS
MANAGEMENT OF A PATIENT PROCESS
TREATMENT PLAN FOR 1O & 2O DxDifferent Sameneeded not needed
Paraclinical Diagnostic Process - Indication
PROCESSING OF DATA
CERTAINTY OF CLINICAL Dx 1O Dx 60% 99%
needed not needed
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process - Indication
Certainty Plan of Treatment
Primary clinical diagnosis 98% SurgicalSecondary clinical diagnosis 1-2% Nonsurgical
Is a paraclinical diagnostic procedure needed?
NO unless there is a strong reason to do so (exception to the rule)
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process - Indication
Certainty Plan of Treatment
Primary clinical diagnosis 60% SurgicalSecondary clinical diagnosis 40% Nonsurgical
Is a paraclinical diagnostic procedure needed?
YES
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process - IndicationTickler -
Which of the following statements is the strongest indication for a paraclinical diagnostic procedure?
A. You can never be absolutely certain of your clinical diagnosisB. You want to confirm a clinical diagnosis which you are certain ofC. You want to document a clinical diagnosis which you are certain ofD. When you are not certain of your clinical diagnosis
Best Answer is D
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS
Options Benefit Risk Cost Availability123
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS Procedure BenefitRisk Cost (PhP) AvailabilityOptions1 most direct acceptable 1000 available2 indirect acceptable 1500 available3 indirect acceptable 1000 available
Which is the most cost-effective procedure?
Option 1
MANAGEMENT OF A PATIENT PROCESS
Informed consent
Paraclinical Diagnostic Process - SelectionSELECTION PROCESS Procedure BenefitRisk Cost (PhP) AvailabilityOptions
1 accuracy 99% acceptable 5000 available2 accuracy 90% acceptable 3000 available3 accuracy 50% acceptable 1000 available
Which is the most cost-effective procedure?
Option 2 or Option 1?
MANAGEMENT OF A PATIENT PROCESS
Informed consent
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS Procedure BenefitRisk Cost (PhP) AvailabilityOptions
1 yield greatest acceptable 4000 available2 yield 90% acceptable 4000 available3 yield 80% acceptable 3000 available
Which is the most cost-effective procedure?
Option 1
MANAGEMENT OF A PATIENT PROCESS
Informed consent
Paraclinical Diagnostic Process - Interpretation
INTERPRETATION PROCESS
CORRELATE
RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE WITH PRIMARY AND SECONDARY CLINICAL DIAGNOSIS
CONGRUENT - ACCEPTINCONGRUENT - MAKE A DECISION!
(Accept or Hold!)
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process - InterpretationTickler -Determine which paraclinical diagnosis should be accepted as the pretreatment diagnosis and which one should be put on hold for further decision-making. Write (A) for accept and (H) for hold.
1. Paraclinical diagnosis is the same as the primary clinical diagnosis.
2. Paraclinical diagnosis is the same as the secondary clinical diagnosis
3. Paraclinical diagnosis is a clinical diagnosis least considered.4. Paraclinical diagnosis does not jibe with the clinical picture or diagnosis.
1. A 2. A 3. H 4. H
MANAGEMENT OF A PATIENT PROCESS
MANAGEMENT OF A PATIENT PROCESSPARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
NO NEED FOR PARACLINICAL DIAGNOSTIC TESTIf very certain of clinical diagnosis and treatment plans for1O & 2O
clinical diagnoses are the same.
Thyroid Papillary Carcinoma
MANAGEMENT OF A PATIENT PROCESSPARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
NO NEED FOR PARACLINICAL DIAGNOSTIC TESTIf very certain of clinical diagnosis and treatment plans for1O & 2O
clinical diagnoses are the same.
Thyroid Follicular Carcinoma
MANAGEMENT OF A PATIENT PROCESSPARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
NO NEED FOR PARACLINICAL DIAGNOSTIC TESTIf very certain of clinical diagnosis and treatment plans for1O & 2O
clinical diagnoses are the same.
Multiple Colloid Adenomatous Goiter
MANAGEMENT OF A PATIENT PROCESSPARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
NEED FOR PARACLINICAL DIAGNOSTIC TEST
If uncertain of thyroid hormonal state (hyperthyroid, euthyroid, hypothyroid),
do thyroid function tests.
MANAGEMENT OF A PATIENT PROCESSPARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
NEED FOR PARACLINICAL DIAGNOSTIC TEST
If uncertain of clinical diagnosis of thyroid structural lesion (malignant, non-malignant),
decide on the options (needle biopsy, ultrasound, thyroid scan, etc.)
MANAGEMENT OF A PATIENT PROCESSPARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
NEED FOR PARACLINICAL DIAGNOSTIC TESTIf uncertain of clinical diagnosis and treatment plans for1O & 2O clinical diagnoses are different
Options for paraclinical diagnostic tests for thyroid nodulesExample of comparative data
Options Benefit Risk Cost Availability
Needle biopsy Direct exam> 90% yield (overall info)
Pain (mild), bleeding and infection (negligible)
PhP1000 Available
Ultrasound Indirect exam<15% yield for ca
Sound wave side effect (negligible)
PhP800 Available
Thyroid scan Indirect exam<12% yield for ca
Radiation (minimal) PhP1200 Available
Informed consent
MANAGEMENT OF A PATIENT PROCESSPARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
NEED FOR PARACLINICAL DIAGNOSTIC TESTIf uncertain of clinical diagnosis and treatment plans for1O & 2O clinical diagnoses are different
Options for paraclinical diagnostic tests for thyroid nodulesExample of comparative dataOptions Benefit Risk Cost Availability
Needle biopsy Direct exam> 90% yield (overall info)
Pain (mild), bleeding and infection (negligible)
PhP1000 Available
Ultrasound Indirect exam<15% yield for ca
Sound wave side effect (negligible)
PhP800 Available
Thyroid scan Indirect exam<12% yield for ca
Radiation (minimal) PhP1200 Available
Informed consent
MANAGEMENT OF A PATIENT PROCESSPARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
FINE NEEDLE ASPIRATION BIOPSY vsNEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON)
Most clinicians, when they do needle aspiration, do not do gross examination of the non-fluid aspirate obtained. They just wait and rely on the report of the pathologists.
I usually do “needle evaluation” rather than just “needle aspiration.”
• Feel the lump with the needle• Examine the aspirate on a gross level• Examine the aspirate through a microscope (through a pathologist)
MANAGEMENT OF A PATIENT PROCESSPARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
FINE NEEDLE ASPIRATION BIOPSY vsNEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON)
Dirty-white bits of tissues from a solid thyroid nodule – PAPILLARY CARCINOMA
MANAGEMENT OF A PATIENT PROCESSPARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
FINE NEEDLE ASPIRATION BIOPSY vsNEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON)
Colloid gelatinous substance in sample – COLLOID ADENOMATOUS NODULE
MANAGEMENT OF A PATIENT PROCESSPARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
FINE NEEDLE ASPIRATION BIOPSY vsNEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON)
Colloid fluid with complete disappearance of mass – COLLOID CYST
MANAGEMENT OF A PATIENT PROCESSPARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
FINE NEEDLE ASPIRATION BIOPSY vsNEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON)
Pus from thyroid nodule – THYROID ABSCESS
MANAGEMENT OF A PATIENT PROCESSPARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
FINE NEEDLE ASPIRATION BIOPSY vsNEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON)
For further reading:
Thyroid nodule aspiration: diagnostic usefulness and limitations.Joson RO; Manalang LR; Ramirez CB; Ick JJA; Avila JM; Abelardo AD. Philipp J Surg Spec 1989;44(2):45-57.
Needle Evaluation of Surface Lumps - 1989
Treatment Process
MANAGEMENT OF A PATIENT PROCESS
Treatment Process - Selection
DATA NEEDED
PRETREATMENT DIAGNOSISSEVERITY OR STAGE
GOALS AND OBJECTIVESTREATMENT OPTIONS
MANAGEMENT OF A PATIENT PROCESS
Treatment Process - Selection
SELECTION PROCESS
Options Benefit Risk Cost Availability123
MANAGEMENT OF A PATIENT PROCESS
Treatment Process - Selection
SELECTION PROCESS Treatment BenefitRisk Cost (PhP) AvailabilityOptions
1 greatest surv rate acceptable 5000 available2 rate < 1 > 3 acceptable 4000 available3 least surv rate acceptable 3000 available
Which is the most cost-effective treatment option?
Option 1
MANAGEMENT OF A PATIENT PROCESS
Informed consent
Treatment Process - Selection
SELECTION PROCESS Treatment BenefitRisk Cost (PhP) AvailabilityOptions
1 SR1 = SR2 lesser 5000 available 2 SR2= SR1 more 5000 available
Which is the more cost-effective treatment option?
Option 1
MANAGEMENT OF A PATIENT PROCESS
Informed consent
Treatment Process - Selection
SELECTION PROCESS Treatment BenefitRisk Cost (PhP) AvailabilityOptions
1 as effective as 2 acceptable 8000 available2 as effective as 1 acceptable 4000 available
Which is the more cost-effective treatment option?
Option 2
MANAGEMENT OF A PATIENT PROCESS
Informed consent
MANAGEMENT OF A PATIENT PROCESSTREATMENT PROCESS
Application in Thyroid Disorders
Grade I to 2 Colloid Adenomatous Nodule or Multiple Colloid Adenomatous GoiterExample of comparative data
Options Benefit Risk Cost Availability
Hormonal Suppressive Therapy
Response rate - 17% - 50% - 76% (88% > 50% reduction)
Medications side effects
PhP 11 / 100mcg tab (may take 12 months) at 2 tabs per day (P660 /month) = P7920 /year
Available
Surgery Resolution of mass in one sitting
Operation side effects
PhP 31,000 (PHIC)
Available
Observation Potential of growing bigger with no medication
No medications / operation side effects
None Available
Informed consent
MANAGEMENT OF A PATIENT PROCESSTREATMENT PROCESS
Application in Thyroid Disorders
Grade 3 Colloid Adenomatous Nodule or Multiple Colloid Adenomatous GoiterExample of comparative data
Options Benefit Risk Cost Availability
Hormonal Suppressive Therapy
Response rate - <5%
Medications side effects
PhP 11 / 100mcg tab (may take 12 months) at 2 tabs per day (P660 /month) = P7920 /year
Available
Surgery Resolution of mass in one sitting
Operation side effects
PhP 31,000 (PHIC) Available
Observation Potential of growing bigger with no medication
No medications / operation side effects
None Available
Informed consent
MANAGEMENT OF A PATIENT PROCESSTREATMENT PROCESS
Application in Thyroid Disorders
Papillary Thyroid Ca, One Lobe, No Nodes, No MetastasisExample of comparative data
Options Benefit Risk Cost Availability
Subtotal Thyroidectomy
10-yr disease-free survival rate – 99%
Hypothyrodism – 13%Permanent hypoparathyroidism – 0.3%
Lower (anesthesia time)
Available
Total Thyroidectomy
10-yr disease-free survival rate – 99%
Hypothyrodism – 100%Permanent hypoparathyroidism – 7%
Higher Available
Informed consent
Cancer Institute Hospital, Tokyo American Association of Endocrine Surgeons (AAES) 2014 Annual Meeting; April 29, 2014; Boston, Massachusetts. Abstract 34.
MANAGEMENT OF A PATIENT PROCESSTREATMENT PROCESS
Application in Thyroid Disorders
Follicular and Papillary Thyroid Ca, One Lobe, No Nodes, No Metastasis Example of comparative data
Options Benefit Risk Cost Availability
Subtotal Thyroidectomy
Survival rate no significant difference with TT
Hypothyrodism – lowerPermanent hypoparathyroidism – lower
Lower (anesthesia time)
Available
Total Thyroidectomy
Survival rate no significant difference with STT
Hypothyrodism – 100%Permanent hypoparathyroidism – higher
Higher Available
Informed consent
Ref: Shaha A., Memorial Sloan-Kettering Cancer Center,Ann N Y Acad Sci. 2008 Sep;1138:58-64. Selective surgical management of well-differentiated thyroid cancer.MD Anderson
MANAGEMENT OF A PATIENT PROCESSTREATMENT PROCESS
Application in Thyroid Disorders
Follicular and Papillary Thyroid Ca, One Lobe, No Nodes, No MetastasisExample of comparative data
Options Benefit Risk Cost Availability
Subtotal Thyroidectomy
Survival rate lower than TT
Hypothyrodism – lowerPermanent hypoparathyroidism – lower
Lower (anesthesia time)
Available
Total Thyroidectomy
Survival rate higher than with STT
Hypothyrodism – 100%Permanent hypoparathyroidism – higher
Higher Available
Informed consentRef: National Comprehensive Cancer Network (NCCN) Guidelines
MANAGEMENT OF A PATIENT PROCESSTREATMENT PROCESS
Application in Thyroid Disorders
Follicular and Papillary Thyroid Ca, One Lobe, No Nodes, No MetastasisExample of comparative data
Options Benefit Risk Cost Availability
Subtotal Thyroidectomy
Survival rate same with TT (Tokyo, Memorial)
Survival rate lower than TT (NCCN)
Hypothyrodism – lowerPermanent hypoparathyroidism – lower
Lower (anesthesia time)
Available
Total Thyroidectomy
Survival rate higher than with STT (NCCN)
Hypothyrodism – 100%Permanent hypoparathyroidism – higher
Higher Available
Informed consent
Conflicting data
MANAGEMENT OF A PATIENT PROCESSTREATMENT PROCESS
Application in Thyroid Disorders
Personal recommendations on thyroid nodule/s:
Operation – if malignant or if there is high chance of malignancy
Trial of hormonal suppressive therapy (levothyroxine) for as long as one year – if benign and not more than 4 cm
If nodule does not disappear, but has decreased in size and remained stationary, maintain on levothyroxine and continue to monitor.
If there is appearance of sign or symptom of malignancy, operate.
Clinical response of nodular colloid adenomatous goitersJoson RO. Philipp J Surg Spec 1998; 53(1):31-34. 1998
MANAGEMENT OF A PATIENT PROCESSTREATMENT PROCESS
Application in Thyroid Disorders
For further reading:
Thyroid Disorders - Indications for Surgery - 1990https://sites.google.com/site/rojosonwritings/thyroid-disorders---indications-for-surgery
Clinical response of nodular colloid adenomatous goitersJoson RO. Philipp J Surg Spec 1998; 53(1):31-34. 1998
MANAGEMENT OF A PATIENT PROCESSTREATMENT PROCESS
Application in Thyroid Disorders
Personal recommendation on extent of thyroidectomy for unilobar well-differentiated thyroid cancers, no nodes, no metastasis:
SUBTOTAL THYROIDECTOMY
I believe in the data of Cancer Institute Hospital, Tokyo and Memorial Sloan-Kettering Cancer Center as they jibe with my personal experience.
Clinical Care Pathway, Management of a Patient Process, and Clinical Practice Guidelines
Clinical Care Pathway
Diagnosis
Treatment
Management of a Patient Process
Clinical diagnostic Paraclinical diagnostic
Treatment
Clinical Practice
Guidelines
Clinical diagnosis
Paraclinical diagnosisTreatment
PROBLEM-SOLVING and DECISION-MAKINGINFORMED CONSENT
Management of a Patient Process and NCCN Guidelines
Options Benefit Risk Cost Availability
2015
1985
Presentation Template
Application of the Management Process in Thyroid Nodules – 30 Years of Experience
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Explanation of the Patient Management Processes
Illustration of Application of Processes
16th Chancellor Alfredo T. Ramirez Memorial Lecture
Application of the Management Process in Thyroid Nodules: Thirty Years
of Experience
52th Postgraduate Course ThemeOncologic Surgery
Current Concepts and Management
Honor ATR
16th Chancellor Alfredo T. Ramirez Memorial
Lecturer
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Dedication and excellence of ATR in medical education and research!