Download atr_lecture_16sept7_roj - ROJoson Medical Clinic

16th Chancellor Alfredo T. Ramirez
MEMORIAL LECTURE
Application of the Management Process in
Thyroid Nodules – 30 Years of Experience
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Family of Dr. Alfredo T. Ramirez
Ms. Bella Yan-Ramirez
Mr. Clark Alfredo Ramirez
Foundation for the Advancement of Surgical
Education, Inc.
Dr. Telesforo Gana
UPCM-PGH Department of Surgery
Dr. Nelson Cabaluna
Postgraduate Courses Committee
Dr. Orlino Bisquera
Surgical Colleagues
Surgical Learners
Friends
Ladies and Gentlemen
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
16th
Chancellor Alfredo T. Ramirez
Memorial Lecturer
For his pioneering spirit
in burns, trauma and
surgical education
For his leadership in
the field of medical and
higher education
For his foresight in
developing advances
in research and
postgraduate surgical training
PRIVILEGE
This memorial lecture is in
recognition of his
dedication, excellence and
contribution in Philippine
surgery.
For his pioneering spirit
in burns, trauma and
surgical
educationgrateful
ROJoson’s
memories
For his leadership
in
to illuminate
the field of medical and
higher education
ATR’s pioneering
leadership
For hisspirit,
foresight
in
developing
and advances
foresight in
in research
and surgical
higher
postgraduate
surgical training
education,
postgraduate
This memorial lecture is in
training
recognition
of his and
dedication,research!
excellence and
contribution in Philippine
surgery.
In 1968,
ATR started
Surgical
Forum,
research
contest for
residents.
In 1968,
ATR
started
Surgical
Forum,
research
contest
for
residents.
1977 Surgical Forum
Tumors of the Parotid Gland – A
Clinicopathologic Study of 139
Cases
Reynaldo O. Joson, MD
Carcinoid Tumors of the
Gastrointestinal Tract
Reynaldo O. Joson, MD
I joined it
from 1977
to 1979.
In 1968,
ATR
started
Surgical
Forum,
research
contest
for
residents.
I joined it
from
1977 to
1979.
1978 Surgical Forum
Early Surgery for Appendiceal
Abscess
Management of External
Gastrointestinal Fistulas
Reynaldo O. Joson, MD
Reynaldo O. Joson, MD
In 1968,
ATR
started
Surgical
Forum,
research
contest for
residents.
1979 Surgical Forum
I joined it
from 1977
to 1979.
Problems and Rehabilitation of
Filipino Stoma Patients
Reynaldo O. Joson, MD
In 1968,
ATR
started
Surgical
Forum,
research
contest for
residents.
I joined it
from 1977
to 1979.
Thanks to ATR!
It gave me great learning opportunity to become a researcher!
ATR as
Chairman of
the
Department
of Surgery
always
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 Surgery
always
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 Surgery
always
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 Surgery
always
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.
Master of Science in Clinical Medicine (Surgery)
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.
ATR initiated Thanks to ATR!
Master of
UPCM is the only institution offering MSc in
Science in
Surgery in the Philippines!
Clinical
Medicine
(Surgery) in
1985.
Dr. Carmela Lapitan
I was the first
graduate in
1998.
Dr. Glenn Genuino
Dr. Mel Anthony Cruz
I was not
required to
take it.
I gave support because I believe in
ATR’s pioneering spirit and foresight
in higher surgical education.
For his pioneering spirit
in burns,
trauma3and
ROJoson’s
grateful
surgical education
memories
to illuminate
For his leadership
in
the field of medical and
pioneering
higherATR’s
education
spirit, leadership
For hisand
foresight
in
foresight
in
developing advances
higher surgical
in research and
education,
postgraduate
surgical training
postgraduate
training
and is in
This memorial
lecture
recognition
of his
research!
dedication, excellence and
contribution
Philippine
Thank inyou,
ATR!
surgery.
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
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 Theme
Oncologic 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
Management of a Patient Process
MD
Patient
Interview
(symptoms
Physical Exam
(signs)
Clinical Diagnostic Processes
(pattern recognition / prevalence)
Goals
Resolution of the Health Problem
Live Patient
No Morbidity
No Disability
Satisfied Patient
No Medico-legal Suit
Clinical Diagnosis
(primary / secondary)
Paraclinical Diagnosis Processes
• Indications (degree of certainty/ effect on tx)
• Selection (benefit / risk / cost / availability)
• Interpretation
Advice
Advice
Pretreatment Diagnosis
Specification of treatment objectives
Advice
Selection of Treatment Options
(benefit / risk / cost / availability)
Advice
Treatment
Advice
Advice
(health maintenance / disease prevention)
Management of a Patient Process
MD
Patient
Interview
(symptoms
Physical Exam
(signs)
Clinical Diagnostic Processes
(pattern recognition / prevalence)
Goals
Resolution of the Health Problem
Live Patient
No Morbidity
No Disability
Satisfied Patient
No Medico-legal Suit
Clinical Diagnosis
(primary / secondary)
Paraclinical Diagnosis Processes
• Indications (degree of certainty/ effect on tx)
• Selection (benefit / risk / cost / availability)
• Interpretation
Advice
Advice
Pretreatment Diagnosis
Specification of treatment objectives
Advice
Selection of Treatment Options
(benefit / risk / cost / availability)
Advice
Treatment
Advice
Advice
(health maintenance / disease prevention)
Presentation Template
Explanation of the Patient Management Processes
Illustration of Application of Processes
Application of the Management Process in Thyroid Nodules
– 30 Years of Experience
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
MANAGEMENT OF A PATIENT PROCESS
PROBLEM-SOLVING AND DECISION-MAKING
UNIVERSAL GOALS
RESOLUTION OF HEALTH PROBLEM
LIVE PATIENT
NO COMPLICATION
NO DISABILITY
SATISFIED PATIENT
NO MEDICOLEGAL SUIT
MANAGEMENT OF A PATIENT PROCESS
PROBLEM-SOLVING AND DECISION-MAKING
UNIVERSAL GOALS
RESOLUTION OF HEALTH PROBLEM (THYROID DISORDER)
LIVE PATIENT
NO COMPLICATION
NO DISABILITY
SATISFIED PATIENT
NO MEDICOLEGAL SUIT
Management of a Patient Process
MD
Patient
Interview
(symptoms
Physical Exam
(signs)
Clinical Diagnostic Processes
(pattern recognition / prevalence)
Clinical Diagnosis
(primary / secondary)
Goals
Resolution of the Health Problem
Live Patient
No Morbidity
No Disability
Satisfied Patient
No Medico-legal Suit
Advice
MANAGEMENT OF A PATIENT PROCESS
CLINICAL DIAGNOSTIC PROCESS
PROCESSING OF DATA (SIGNS and SYMPTOMS)
PATTERN RECOGNITION (MATCHING)
- realization that the patient’s presentation
conforms 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 PROCESS
CLINICAL DIAGNOSTIC PROCESS
PROCESSING OF DATA
Knowing the common manifestations of 5 different diseases as
follows:
Disease A - abcd (manifestations)
Disease B - fghi
Disease C - klmn
Disease D - pqrs
Disease E – uvwx
Given a patient manifesting with pqrs, your diagnosis is Disease D.
What is the process used?
Pattern Recognition
MANAGEMENT OF A PATIENT PROCESS
CLINICAL 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 common
Disease 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 PROCESS
CLINICAL 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 PROCESS
CLINICAL 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
Acute thyroiditis / abscess
Chronic thyroiditis
Difficult
√
Difficult
Hyperthyroidism
√
Hypothyroidism
√
MANAGEMENT OF A PATIENT PROCESS
CLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence
Application in Thyroid Disorders
Primary Clinical Diagnosis
Diffuse colloid adenomatous goiter
Signs and Symptoms
Diffuse goiter
PR < 90 / min
No signs of malignancy
MANAGEMENT OF A PATIENT PROCESS
CLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence
Application in Thyroid Disorders
Primary Clinical Diagnosis
Colloid adenomatous nodule/colloid cyst
Signs and Symptoms
Solitary thyroid nodule
Not hard, solid / complex / cystic
PR < 90 /min
No signs of malignancy
MANAGEMENT OF A PATIENT PROCESS
CLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence
Application in Thyroid Disorders
Primary Clinical Diagnosis
Multiple colloid adenomatous goiter
Signs and Symptoms
Multiple thyroid nodules
Not hard
PR < 90 / min
No signs of malignancy
MANAGEMENT OF A PATIENT PROCESS
CLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence
Application in Thyroid Disorders
Primary Clinical Diagnosis
Papillary carcinoma
Signs and Symptoms
Solitary thyroid nodule
Hard solid
PR < 90 / min
MANAGEMENT OF A PATIENT PROCESS
CLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence
Application in Thyroid Disorders
Primary Clinical Diagnosis
Papillary carcinoma
Signs and Symptoms
Solitary thyroid nodule
Hard solid
No compression (dysphagia, dyspnea)
Ipsilateral neck node/s
PR < 90 / min
MANAGEMENT OF A PATIENT PROCESS
CLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence
Application in Thyroid Disorders
Primary Clinical Diagnosis
Follicular carcinoma
Signs and Symptoms
Solitary thyroid nodule
Lytic bone lesion suspicious of metastasis
No compression (dysphagia, dyspnea)
PR < 90 / min
MANAGEMENT OF A PATIENT PROCESS
CLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence
Application in Thyroid Disorders
Primary Clinical Diagnosis
Anaplastic carcinoma
Signs and Symptoms
Huge thyroid mass, fixed
Neck compression (dysphagia, dyspnea)
PR < 90 / min
Elderly
MANAGEMENT OF A PATIENT PROCESS
CLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence
Application in Thyroid Disorders
Primary Clinical Diagnosis
Acute thyroiditis / abscess
Signs and Symptoms
Tender fluctuant thyroid mass
No signs of malignancy
MANAGEMENT OF A PATIENT PROCESS
CLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence
Application in Thyroid Disorders
Primary Clinical Diagnosis
Chronic thyroiditis
Signs and Symptoms
Nodular gland with no discrete mass
PR < 90 / min
No signs of malignancy
MANAGEMENT OF A PATIENT PROCESS
CLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence
Application in Thyroid Disorders
Primary Clinical Diagnosis
Hyperthyroidism
Signs and Symptoms
Diffuse goiter
PR > 100/ min
Sudden weight loss
With / without exophthalmos
MANAGEMENT OF A PATIENT PROCESS
CLINICAL DIAGNOSTIC PROCESS
Pattern Recognition and Prevalence
Application in Thyroid Disorders
Primary Clinical Diagnosis
Hypothyroidism
Signs and Symptoms
Diffuse goiter
PR < 90/ min
Short obese stature with unusually slow
body movement
MANAGEMENT OF A PATIENT PROCESS
CLINICAL 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 PROCESS
CLINICAL 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 - 1985
http://www.slideshare.net/rjoson/clinical-diagnosis-of-thyroiddisorders
Thyroid Surgical Diseases - 1986
MANAGEMENT OF A PATIENT PROCESS
Paraclinical
Diagnostic Process
Management of a Patient Process
MD
Patient
Interview
(symptoms
Physical Exam
(signs)
Clinical Diagnostic Processes
(pattern recognition / prevalence)
Goals
Resolution of the Health Problem
Live Patient
No Morbidity
No Disability
Satisfied Patient
No Medico-legal Suit
Clinical Diagnosis
(primary / secondary)
Paraclinical Diagnosis Processes
• Indications (degree of certainty/ effect on tx)
• Selection (benefit / risk / cost / availability)
• Interpretation
Pretreatment Diagnosis
Specification of treatment objectives
Advice
Advice
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process
Indication - to be more definite on the clinical diagnosis
Selection
Interpretation
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process - Indication
DATA NEEDED
PRIMARY CLINICAL DIAGNOSIS
SECONDARY CLINICAL DIAGNOSIS
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process - Indication
PROCESSING OF DATA
CERTAINTY OF CLINICAL Dx
1O Dx 60%
needed
99%
not needed
TREATMENT PLAN FOR 1O & 2O Dx
Different
needed
Same
not needed
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process - Indication
Primary clinical diagnosis
Secondary clinical diagnosis
Certainty
Plan of Treatment
98%
1-2%
Surgical
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
Primary clinical diagnosis
Secondary clinical diagnosis
Certainty
Plan of Treatment
60%
40%
Surgical
Nonsurgical
Is a paraclinical diagnostic procedure needed?
YES
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process - Indication
Tickler -
Which of the following statements is the strongest indication for a
paraclinical diagnostic procedure?
A. You can never be absolutely certain of your clinical diagnosis
B. You want to confirm a clinical diagnosis which you are certain of
C. You want to document a clinical diagnosis which you are certain of
D. 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
1
2
3
Benefit
Risk
Cost
Availability
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS
Procedure
Benefit
Options
1
most direct
2
indirect
3
indirect
Risk
Cost (PhP)
Availability
acceptable
acceptable
acceptable
1000
1500
1000
available
available
available
Which is the most cost-effective procedure?
Informed consent
Option 1
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS
Procedure
Benefit
Options
1
2
3
Risk
accuracy 99% acceptable
accuracy 90% acceptable
accuracy 50% acceptable
Cost (PhP)
Availability
5000
3000
1000
available
available
available
Which is the most cost-effective procedure?
Informed consent
Option 2 or Option 1?
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS
Procedure
Benefit
Options
1
2
3
Risk
yield greatest acceptable
yield 90%
acceptable
yield 80%
acceptable
Cost (PhP)
Availability
4000
4000
3000
available
available
available
Which is the most cost-effective procedure?
Option 1
Informed consent
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process - Interpretation
INTERPRETATION PROCESS
CORRELATE
RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE
WITH
PRIMARY AND SECONDARY CLINICAL DIAGNOSIS
CONGRUENT - ACCEPT
INCONGRUENT - MAKE A DECISION!
(Accept or Hold!)
MANAGEMENT OF A PATIENT PROCESS
Paraclinical Diagnostic Process - Interpretation
Tickler 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
PARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
NO NEED FOR PARACLINICAL DIAGNOSTIC TEST
If very certain of clinical diagnosis and treatment plans for1O & 2O
clinical diagnoses are the same.
Thyroid Papillary Carcinoma
MANAGEMENT OF A PATIENT PROCESS
PARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
NO NEED FOR PARACLINICAL DIAGNOSTIC TEST
If very certain of clinical diagnosis and treatment plans for1O & 2O
clinical diagnoses are the same.
Thyroid Follicular Carcinoma
MANAGEMENT OF A PATIENT PROCESS
PARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
NO NEED FOR PARACLINICAL DIAGNOSTIC TEST
If very certain of clinical diagnosis and treatment plans for1O & 2O
clinical diagnoses are the same.
Multiple Colloid Adenomatous Goiter
MANAGEMENT OF A PATIENT PROCESS
PARACLINICAL 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 PROCESS
PARACLINICAL 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 PROCESS
PARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
NEED FOR PARACLINICAL DIAGNOSTIC TEST
If uncertain of clinical diagnosis and treatment plans for1O & 2O clinical
diagnoses are different
Options for paraclinical diagnostic tests for thyroid nodules
Example of comparative data
Options
Benefit
Risk
Cost
Availability
Needle biopsy
Direct exam
> 90% yield
(overall info)
Pain (mild), bleeding PhP1000
and infection
(negligible)
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 PROCESS
PARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
NEED FOR PARACLINICAL DIAGNOSTIC TEST
If uncertain of clinical diagnosis and treatment plans for1O & 2O clinical
diagnoses are different
Options for paraclinical diagnostic tests for thyroid nodules
Example of comparative data
Options
Benefit
Risk
Cost
Needle biopsy
Direct exam
> 90% yield
(overall info)
Pain (mild), bleeding PhP1000
and infection
(negligible)
Available
Ultrasound
Indirect exam
<15% yield for ca
Sound wave
side
PhP800
Informed
consent
effect (negligible)
Available
Thyroid scan
Indirect exam
<12% yield for ca
Radiation (minimal)
Available
PhP1200
Availability
MANAGEMENT OF A PATIENT PROCESS
PARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
FINE NEEDLE ASPIRATION BIOPSY
vs
NEEDLE 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 PROCESS
PARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
FINE NEEDLE ASPIRATION BIOPSY
vs
NEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON)
Dirty-white bits of tissues from a solid thyroid nodule – PAPILLARY
CARCINOMA
MANAGEMENT OF A PATIENT PROCESS
PARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
FINE NEEDLE ASPIRATION BIOPSY
vs
NEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON)
Colloid gelatinous substance in sample – COLLOID ADENOMATOUS
NODULE
MANAGEMENT OF A PATIENT PROCESS
PARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
FINE NEEDLE ASPIRATION BIOPSY
vs
NEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON)
Colloid fluid with complete disappearance of mass – COLLOID CYST
MANAGEMENT OF A PATIENT PROCESS
PARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
FINE NEEDLE ASPIRATION BIOPSY
vs
NEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON)
Pus from thyroid nodule – THYROID ABSCESS
MANAGEMENT OF A PATIENT PROCESS
PARACLINICAL DIAGNOSTIC PROCESS
Application in Thyroid Disorders
FINE NEEDLE ASPIRATION BIOPSY
vs
NEEDLE 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
MANAGEMENT OF A PATIENT PROCESS
Treatment Process
MANAGEMENT OF A PATIENT PROCESS
Treatment Process - Selection
DATA NEEDED
PRETREATMENT DIAGNOSIS
SEVERITY OR STAGE
GOALS AND OBJECTIVES
TREATMENT OPTIONS
MANAGEMENT OF A PATIENT PROCESS
Treatment Process - Selection
SELECTION PROCESS
Options
1
2
3
Benefit
Risk
Cost
Availability
MANAGEMENT OF A PATIENT PROCESS
Treatment Process - Selection
SELECTION PROCESS
Treatment
Benefit
Options
Risk
Cost (PhP)
Availability
1
2
3
acceptable
acceptable
acceptable
5000
4000
3000
available
available
available
greatest surv rate
rate < 1 > 3
least surv rate
Which is the most cost-effective treatment option?
Option 1
Informed consent
MANAGEMENT OF A PATIENT PROCESS
Treatment Process - Selection
SELECTION PROCESS
Treatment
Benefit
Options
Risk
Cost (PhP)
Availability
1
2
lesser
more
5000
5000
available
available
SR1 = SR2
SR2= SR1
Which is the more cost-effective treatment option?
Option 1
Informed consent
MANAGEMENT OF A PATIENT PROCESS
Treatment Process - Selection
SELECTION PROCESS
Treatment
Benefit
Options
Risk
Cost (PhP)
Availability
1
2
acceptable
acceptable
8000
4000
available
available
as effective as 2
as effective as 1
Which is the more cost-effective treatment option?
Option 2
Informed consent
MANAGEMENT OF A PATIENT PROCESS
TREATMENT PROCESS
Application in Thyroid Disorders
Grade I to 2 Colloid Adenomatous Nodule or
Multiple Colloid Adenomatous Goiter
Example of comparative data
Options
Benefit
Risk
Cost
Availability
Hormonal
Suppressive
Therapy
Response rate - Medications
17% - 50% side effects
76% (88% >
50% reduction)
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
PhP 31,000
(PHIC)
Available
Observation
Potential of
No medications None
growing bigger / operation
with no
side effects
medication
Operation side
effects
Available
Informed consent
MANAGEMENT OF A PATIENT PROCESS
TREATMENT PROCESS
Application in Thyroid Disorders
Grade 3 Colloid Adenomatous Nodule or Multiple
Colloid Adenomatous Goiter
Example of comparative data
Options
Benefit
Risk
Cost
Availability
Hormonal
Response rate Medications
Suppressive - <5%
side effects
Therapy
PhP 11 / 100mcg tab
(may take 12 months)
at 2 tabs per day
(P660 /month) =
P7920 /year
Available
Surgery
PhP 31,000 (PHIC)
Available
Resolution of
mass in one
sitting
Observation Potential of
growing
bigger with no
medication
Operation
side effects
No
None
medications /
operation
side effects
Available
Informed consent
MANAGEMENT OF A PATIENT PROCESS
TREATMENT PROCESS
Application in Thyroid Disorders
Papillary Thyroid Ca, One Lobe, No Nodes, No Metastasis
Example of comparative data
Options
Benefit
Risk
Cost
Availability
Subtotal
10-yr diseaseThyroidectomy free survival
rate – 99%
Hypothyrodism –
13%
Permanent
hypoparathyroidism
– 0.3%
Lower
Available
(anesthesia
time)
Total
10-yr diseaseThyroidectomy free survival
rate – 99%
Hypothyrodism –
100%
Permanent
hypoparathyroidism
– 7%
Higher
Cancer Institute Hospital, Tokyo
American Association of Endocrine Surgeons (AAES) 2014
Annual Meeting; April 29, 2014; Boston, Massachusetts.
Abstract 34.
Available
Informed consent
MANAGEMENT OF A PATIENT PROCESS
TREATMENT 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
Survival rate
Thyroidectomy no significant
difference with
TT
Hypothyrodism –
Lower
Available
lower
(anesthesia
Permanent
time)
hypoparathyroidism
– lower
Total
Survival rate
Thyroidectomy no significant
difference with
STT
Hypothyrodism –
Higher
100%
Permanent
hypoparathyroidism
– higher
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
Available
Informed consent
MANAGEMENT OF A PATIENT PROCESS
TREATMENT 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
Survival rate
Thyroidectomy lower than TT
Hypothyrodism –
lower
Permanent
hypoparathyroidism
– lower
Lower
Available
(anesthesia
time)
Total
Survival rate
Thyroidectomy higher than
with STT
Hypothyrodism –
100%
Permanent
hypoparathyroidism
– higher
Higher
Ref: National Comprehensive Cancer
Network (NCCN) Guidelines
Available
Informed consent
MANAGEMENT OF A PATIENT PROCESS
TREATMENT PROCESS
Application in Thyroid Disorders
Follicular and Papillary Thyroid Ca, One Lobe, No Nodes, No Metastasis
Example of comparative data
Options
Benefit
Subtotal
Survival rate
Thyroidectomy same with TT
(Tokyo,
Memorial)
Conflicting
data
Risk
Cost
Availability
Hypothyrodism –
Lower
Available
lower
(anesthesia
Permanent
time)
hypoparathyroidism
– lower
Survival rate
lower than TT
(NCCN)
Total
Survival rate
Thyroidectomy higher than
with STT
(NCCN)
Hypothyrodism –
Higher
Available
100%
Permanent
hypoparathyroidism
Informed consent
– higher
MANAGEMENT OF A PATIENT PROCESS
TREATMENT 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 goiters
Joson RO. Philipp J Surg Spec 1998; 53(1):31-34. 1998
MANAGEMENT OF A PATIENT PROCESS
TREATMENT PROCESS
Application in Thyroid Disorders
For further reading:
Thyroid Disorders - Indications for Surgery - 1990
https://sites.google.com/site/rojosonwritings/thyroid-disorders--indications-for-surgery
Clinical response of nodular colloid adenomatous goiters
Joson RO. Philipp J Surg Spec 1998; 53(1):31-34. 1998
MANAGEMENT OF A PATIENT PROCESS
TREATMENT 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
Management of a
Patient Process
Clinical diagnostic
Paraclinical diagnostic
Treatment
Treatment
Clinical
Practice
Guidelines
Clinical
diagnosis
Paraclinical
diagnosis
Treatment
PROBLEM-SOLVING and DECISION-MAKING
INFORMED CONSENT
Management of a Patient Process and NCCN Guidelines
1985
Options
2015
Benefit
Risk
Cost
Availability
Presentation Template
Explanation of the Patient Management Processes
Illustration of Application of Processes
Application of the Management Process in Thyroid Nodules
– 30 Years of Experience
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
16th
Chancellor Alfredo T. Ramirez Memorial Lecture
Application of the Management Process in
Thyroid Nodules: Thirty Years of
Experience
52th Postgraduate Course Theme
Oncologic Surgery
Current Concepts and Management
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
16th
Chancellor Alfredo T. Ramirez Memorial
Lecturer
Dedication and excellence of ATR in medical education and
research!