Application of the Management Process in Thyroid Nodules

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


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




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.


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



1978 Surgical Forum

Management of External Gastrointestinal Fistulas

Reynaldo O. Joson, MD

Early Surgery for Appendiceal Abscess Reynaldo O. Joson, MD



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!



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


Motivation and Encouragement

Citation

UPCM Year Level V


Letter of Commendation and Promotion

Assistant Professor IV(1991)


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




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


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


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



PatientMD




Interview(symptoms




Advice(health maintenance / disease prevention)


Advice

Advice

Advice

Advice

Advice

Selection of Treatment Options(benefit / risk / cost / availability)

Treatment

Presentation Template



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


PatientMD




Interview(symptoms



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


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


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


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!


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 √



Primary Clinical Diagnosis Signs and Symptoms

Diffuse colloid adenomatous goiter Diffuse goiterPR < 90 / min

No signs of malignancy




Colloid adenomatous nodule/colloid cyst Solitary thyroid noduleNot hard, solid / complex / cystic

PR < 90 /minNo signs of malignancy




Multiple colloid adenomatous goiter Multiple thyroid nodulesNot hard

PR < 90 / minNo signs of malignancy




Papillary carcinoma Solitary thyroid noduleHard solid

PR < 90 / min




Papillary carcinoma Solitary thyroid noduleHard solid

No compression (dysphagia, dyspnea)Ipsilateral neck node/s

PR < 90 / min




Follicular carcinoma Solitary thyroid noduleLytic bone lesion suspicious of metastasis

No compression (dysphagia, dyspnea)PR < 90 / min




Anaplastic carcinoma Huge thyroid mass, fixedNeck compression (dysphagia, dyspnea)

PR < 90 / minElderly




Acute thyroiditis / abscess Tender fluctuant thyroid massNo signs of malignancy




Chronic thyroiditis Nodular gland with no discrete massPR < 90 / min

No signs of malignancy




Hyperthyroidism Diffuse goiterPR > 100/ min

Sudden weight lossWith / without exophthalmos




Hypothyroidism Diffuse goiterPR < 90/ min

Short obese stature with unusually slow body movement




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!




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



PatientMD




Interview(symptoms





Advice

Advice


Paraclinical Diagnostic ProcessIndication - to be more definite on the clinical diagnosis

Selection

Interpretation

Paraclinical Diagnostic Process - Indication

DATA NEEDED

PRIMARY CLINICAL DIAGNOSISSECONDARY CLINICAL DIAGNOSIS


TREATMENT PLAN FOR 1O & 2O DxDifferent Sameneeded not needed


PROCESSING OF DATA

CERTAINTY OF CLINICAL Dx 1O Dx 60% 99%

needed not needed



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)



Certainty Plan of Treatment

Primary clinical diagnosis 60% SurgicalSecondary clinical diagnosis 40% Nonsurgical

Is a paraclinical diagnostic procedure needed?

YES


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


Paraclinical Diagnostic Process - Selection

SELECTION PROCESS

Options Benefit Risk Cost Availability123



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


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


Option 2 or Option 1?


Informed consent


SELECTION PROCESS Procedure BenefitRisk Cost (PhP) AvailabilityOptions

1 yield greatest acceptable 4000 available2 yield 90% acceptable 4000 available3 yield 80% acceptable 3000 available


Option 1


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!)


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 PROCESSPARACLINICAL DIAGNOSTIC PROCESS


NO NEED FOR PARACLINICAL DIAGNOSTIC TESTIf very certain of clinical diagnosis and treatment plans for1O & 2O

clinical diagnoses are the same.

Thyroid Papillary Carcinoma





Thyroid Follicular Carcinoma





Multiple Colloid Adenomatous Goiter



NEED FOR PARACLINICAL DIAGNOSTIC TEST

If uncertain of thyroid hormonal state (hyperthyroid, euthyroid, hypothyroid),

do thyroid function tests.



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.)



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



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



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)




Dirty-white bits of tissues from a solid thyroid nodule – PAPILLARY CARCINOMA




Colloid gelatinous substance in sample – COLLOID ADENOMATOUS NODULE




Colloid fluid with complete disappearance of mass – COLLOID CYST




Pus from thyroid nodule – THYROID ABSCESS




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


Treatment Process - Selection

DATA NEEDED

PRETREATMENT DIAGNOSISSEVERITY OR STAGE

GOALS AND OBJECTIVESTREATMENT OPTIONS



SELECTION PROCESS

Options Benefit Risk Cost Availability123



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


Informed consent



1 SR1 = SR2 lesser 5000 available 2 SR2= SR1 more 5000 available

Which is the more cost-effective treatment option?

Option 1


Informed consent



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


Informed consent

MANAGEMENT OF A PATIENT PROCESSTREATMENT PROCESS


Grade I to 2 Colloid Adenomatous Nodule or Multiple Colloid Adenomatous GoiterExample of comparative data


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



Grade 3 Colloid Adenomatous Nodule or Multiple Colloid Adenomatous GoiterExample of comparative data


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



Papillary Thyroid Ca, One Lobe, No Nodes, No MetastasisExample of comparative data


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.



Follicular and Papillary Thyroid Ca, One Lobe, No Nodes, No Metastasis Example of comparative data



Survival rate no significant difference with TT

Hypothyrodism – lowerPermanent hypoparathyroidism – lower


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



Follicular and Papillary Thyroid Ca, One Lobe, No Nodes, No MetastasisExample of comparative data



Survival rate lower than TT



Available

Total Thyroidectomy

Survival rate higher than with STT


Higher Available

Informed consentRef: National Comprehensive Cancer Network (NCCN) Guidelines



Follicular and Papillary Thyroid Ca, One Lobe, No Nodes, No MetastasisExample of comparative data



Survival rate same with TT (Tokyo, Memorial)

Survival rate lower than TT (NCCN)



Available

Total Thyroidectomy

Survival rate higher than with STT (NCCN)


Higher Available

Informed consent

Conflicting data



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



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



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


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


2015

1985

Presentation Template



Explanation of the Patient Management Processes

Illustration of Application of Processes


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


Dedication and excellence of ATR in medical education and research!

Health & Medicine

Application of the Management Process in Thyroid Nodules