Application of the Management Process in Thyroid Nodules

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

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
This memorial lecture is in
recognition of his
dedication, excellence and
contribution in Philippine
surgery.PRIVILEGE

surgical education
higher education
developing advances
in research and
recognition of his
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
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

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 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.
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 Lapitan
Dr. Glenn Genuino
Dr. Mel Anthony Cruz

surgical education
higher education
developing advances
in research and
recognition of his
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!

16th
Chancellor Alfredo T. Ramirez Memorial
Lecturer
Dedication and excellence of ATR in medical education and
research!

16th
Chancellor Alfredo T. Ramirez Memorial
Lecture
Thyroid Nodules: Thirty Years of
Experience
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

16th
Chancellor Alfredo T. Ramirez Memorial Lecture
Experience
52th Postgraduate Course Theme
Oncologic Surgery
Current Concepts and Management

16th
Chancellor Alfredo T. Ramirez Memorial Lecture
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 Diagnosis
Specification of treatment objectives
Management of a Patient Process
Patient
MD
Goals
Resolution of the Health Problem
Live Patient
No Morbidity
No Disability
Satisfied Patient
No 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
Explanation of the Patient Management Processes
Illustration of Application of Processes

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

PROBLEM-SOLVING AND DECISION-MAKING
UNIVERSAL GOALS
RESOLUTION OF HEALTH PROBLEM (THYROID DISORDER)
LIVE PATIENT
NO COMPLICATION
NO DISABILITY
SATISFIED PATIENT
NO MEDICOLEGAL SUIT

Patient
MD
Goals
Live Patient
No Morbidity
No Disability
Satisfied Patient
Interview
(symptoms
Physical Exam
(signs)
Clinical Diagnosis
Advice

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

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

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

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!

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 goiter
PR < 90 / min
No signs of malignancy

Colloid adenomatous nodule/colloid cyst Solitary thyroid nodule
Not hard, solid / complex / cystic
PR < 90 /min

Multiple colloid adenomatous goiter Multiple thyroid nodules
Not hard
PR < 90 / min

Papillary carcinoma Solitary thyroid nodule
Hard solid
PR < 90 / min

Papillary carcinoma Solitary thyroid nodule
Hard solid
No compression (dysphagia, dyspnea)
Ipsilateral neck node/s
PR < 90 / min

Follicular carcinoma Solitary thyroid nodule
Lytic bone lesion suspicious of metastasis
No compression (dysphagia, dyspnea)
PR < 90 / min

Anaplastic carcinoma Huge thyroid mass, fixed
Neck compression (dysphagia, dyspnea)
PR < 90 / min
Elderly

Acute thyroiditis / abscess Tender fluctuant thyroid mass

Chronic thyroiditis Nodular gland with no discrete mass
PR < 90 / min

Hyperthyroidism Diffuse goiter
PR > 100/ min
Sudden weight loss
With / without exophthalmos

Hypothyroidism Diffuse goiter
PR < 90/ min
Short obese stature with unusually slow
body movement

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-thyroid-
disorders
Thyroid Surgical Diseases - 1986

Paraclinical
Diagnostic Process

Pretreatment Diagnosis
Specification of treatment objectives
Patient
MD
Goals
Live Patient
No Morbidity
No Disability
Satisfied Patient
Interview
(symptoms
Physical Exam
(signs)
Clinical Diagnosis
Paraclinical Diagnosis Processes
• Indications (degree of certainty/ effect on tx)
• Selection (benefit / risk / cost / availability)
• Interpretation
Advice
Advice

Paraclinical Diagnostic Process
Indication - to be more definite on the clinical diagnosis
Selection
Interpretation

Paraclinical Diagnostic Process - Indication
DATA NEEDED
PRIMARY CLINICAL DIAGNOSIS
SECONDARY CLINICAL DIAGNOSIS

TREATMENT PLAN FOR 1O & 2O Dx
Different Same
needed not needed
PROCESSING OF DATA
CERTAINTY OF CLINICAL Dx
1O Dx 60% 99%
needed not needed

Certainty Plan of Treatment
Primary clinical diagnosis 98% Surgical
Secondary 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% Surgical
Secondary clinical diagnosis 40% Nonsurgical
Is a paraclinical diagnostic procedure needed?
YES

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

Paraclinical Diagnostic Process - Selection
SELECTION PROCESS
Options Benefit Risk Cost Availability
1
2
3

SELECTION PROCESS
Procedure Benefit Risk Cost (PhP) Availability
Options
1 most direct acceptable 1000 available
2 indirect acceptable 1500 available
3 indirect acceptable 1000 available
Which is the most cost-effective procedure?
Option 1
Informed consent

SELECTION PROCESS
Options
1 accuracy 99% acceptable 5000 available
Option 2 or Option 1?
Informed consent

SELECTION PROCESS
Options
1 yield greatest acceptable 4000 available
2 yield 90% acceptable 4000 available
3 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 - ACCEPT
INCONGRUENT - MAKE A DECISION!
(Accept or Hold!)

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

PARACLINICAL DIAGNOSTIC PROCESS
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

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.

If uncertain of clinical diagnosis of thyroid
structural lesion (malignant, non-malignant),
decide on the options (needle biopsy,
ultrasound, thyroid scan, etc.)

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
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
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)

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

vs
Colloid gelatinous substance in sample – COLLOID ADENOMATOUS
NODULE

vs
Colloid fluid with complete disappearance of mass – COLLOID CYST

vs
Pus from thyroid nodule – THYROID ABSCESS

vs
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 DIAGNOSIS
SEVERITY OR STAGE
GOALS AND OBJECTIVES
TREATMENT OPTIONS

SELECTION PROCESS
1
2
3

SELECTION PROCESS
Treatment Benefit Risk Cost (PhP) Availability
Options
1 greatest surv rate acceptable 5000 available
2 rate < 1 > 3 acceptable 4000 available
3 least surv rate acceptable 3000 available
Which is the most cost-effective treatment option?
Option 1
Informed consent

SELECTION PROCESS
Options
1 SR1 = SR2 lesser 5000 available
2 SR2= SR1 more 5000 available
Which is the more cost-effective treatment option?
Option 1
Informed consent

SELECTION PROCESS
Options
1 as effective as 2 acceptable 8000 available
2 as effective as 1 acceptable 4000 available
Which is the more cost-effective treatment option?
Option 2
Informed consent

TREATMENT PROCESS
Grade I to 2 Colloid Adenomatous Nodule or
Multiple Colloid Adenomatous Goiter
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

TREATMENT PROCESS
Grade 3 Colloid Adenomatous Nodule or Multiple
Colloid Adenomatous Goiter
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

TREATMENT PROCESS
Papillary Thyroid Ca, One Lobe, No Nodes, No Metastasis
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.

TREATMENT PROCESS
Follicular and Papillary Thyroid Ca, One Lobe, No Nodes, No Metastasis
Subtotal
Thyroidectomy
Survival rate
no significant
difference with
TT
Hypothyrodism –
lower
Permanent
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

TREATMENT PROCESS
Subtotal
Thyroidectomy
Survival rate
lower than TT
Hypothyrodism –
lower
Permanent
hypoparathyroidism
– lower
Lower
(anesthesia
time)
Available
Total
Thyroidectomy
Survival rate
higher than
with STT
Hypothyrodism –
100%
Permanent
hypoparathyroidism
– higher
Higher Available
Informed consent
Ref: National Comprehensive Cancer
Network (NCCN) Guidelines

TREATMENT PROCESS
Subtotal
Thyroidectomy
Survival rate
same with TT
(Tokyo,
Memorial)
Survival rate
lower than TT
(NCCN)
Hypothyrodism –
lower
Permanent
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

TREATMENT PROCESS
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

TREATMENT PROCESS
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

TREATMENT PROCESS
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
diagnosis
Treatment
PROBLEM-SOLVING and DECISION-MAKING
INFORMED CONSENT

Management of a Patient Process and NCCN Guidelines
2015
1985

Application of the Management Process in Thyroid Nodules

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