16th Chancellor Alfredo T. Ramirez MEMORIAL LECTURE

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 Mr. Clark Alfredo Ramirez
Greetings Family of Dr. Alfredo T. Ramirez Ms. Bella Yan-Ramirez Mr. Clark Alfredo Ramirez

Greetings 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

Greetings Surgical Colleagues Surgical Learners Friends
Ladies and Gentlemen

Honor 16th Chancellor Alfredo T. Ramirez Memorial Lecturer
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 This memorial lecture is in recognition of his dedication, excellence and contribution in Philippine surgery. PRIVILEGE

ROJoson’s grateful memories
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. 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.

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. 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

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 Reynaldo O. Joson, MD Management of External Gastrointestinal Fistulas 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

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!

Letter of Commendation and Encouragement
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

Motivation and Encouragement Citation
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

Letter of Commendation and Promotion Assistant Professor IV
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)

Thanks to ATR! ATR as Chairman of the Department of Surgery
always encouraged and motivated me to excel in being a medical educator. Thanks to ATR!

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. Master of Science in Clinical Medicine (Surgery) I gave support because I believe in ATR’s pioneering spirit and foresight in higher surgical education.

Dr. Carmela Lapitan Dr. Glenn Genuino Dr. Mel Anthony Cruz
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. 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 I gave support because I believe in ATR’s pioneering spirit and foresight in higher surgical education.

ROJoson’s 3 grateful memories
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. 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 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

52th Postgraduate Course Theme Current Concepts and Management
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
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
Goals Resolution of the Health Problem Live Patient No Morbidity No Disability Satisfied Patient No Medico-legal Suit MD Patient Interview (symptoms Physical Exam (signs) Clinical Diagnostic Processes (pattern recognition / prevalence) Clinical Diagnosis (primary / secondary) Advice Paraclinical Diagnosis Processes Indications (degree of certainty/ effect on tx) Selection (benefit / risk / cost / availability) Interpretation 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 Advice
Goals Resolution of the Health Problem Live Patient No Morbidity No Disability Satisfied Patient No Medico-legal Suit MD Patient Interview (symptoms Physical Exam (signs) Clinical Diagnostic Processes (pattern recognition / prevalence) Clinical Diagnosis (primary / secondary) 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

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

Pattern Recognition but mainly Prevalence
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

Application in Thyroid Disorders
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!

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 Hyperthyroidism Hypothyroidism

Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Signs and Symptoms Diffuse colloid adenomatous goiter Diffuse goiter PR < 90 / min No signs of malignancy

Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Signs and Symptoms Colloid adenomatous nodule/colloid cyst Solitary thyroid nodule Not hard, solid / complex / cystic PR < 90 /min No signs of malignancy

Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Signs and Symptoms Multiple colloid adenomatous goiter Multiple thyroid nodules Not hard PR < 90 / min No signs of malignancy

Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Signs and Symptoms Papillary carcinoma Solitary thyroid nodule Hard solid PR < 90 / min

Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Signs and Symptoms Papillary carcinoma Solitary thyroid nodule Hard solid No compression (dysphagia, dyspnea) Ipsilateral neck node/s PR < 90 / min

Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Signs and Symptoms Follicular carcinoma Solitary thyroid nodule Lytic bone lesion suspicious of metastasis No compression (dysphagia, dyspnea) PR < 90 / min

Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Signs and Symptoms Anaplastic carcinoma Huge thyroid mass, fixed Neck compression (dysphagia, dyspnea) PR < 90 / min Elderly

Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Signs and Symptoms Acute thyroiditis / abscess Tender fluctuant thyroid mass No signs of malignancy

Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Signs and Symptoms Chronic thyroiditis Nodular gland with no discrete mass PR < 90 / min No signs of malignancy

Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Signs and Symptoms Hyperthyroidism Diffuse goiter PR > 100/ min Sudden weight loss With / without exophthalmos

Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Signs and Symptoms Hypothyroidism 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 Thyroid Surgical Diseases

MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process

Management of a Patient Process MD Patient Advice Advice
Goals Resolution of the Health Problem Live Patient No Morbidity No Disability Satisfied Patient No Medico-legal Suit MD Patient Interview (symptoms Physical Exam (signs) Clinical Diagnostic Processes (pattern recognition / prevalence) Clinical Diagnosis (primary / secondary) Advice Paraclinical Diagnosis Processes Indications (degree of certainty/ effect on tx) Selection (benefit / risk / cost / availability) Interpretation Advice Pretreatment Diagnosis Specification of treatment objectives

MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process
Indication - to be more definite on the clinical diagnosis Selection Interpretation

Paraclinical Diagnostic Process - Indication
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 not needed TREATMENT PLAN FOR 1O & 2O Dx Different Same needed not needed

MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process - Indication Certainty Plan of Treatment Primary clinical diagnosis % Surgical Secondary clinical diagnosis % 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 % Surgical Secondary clinical diagnosis % 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

Paraclinical Diagnostic Process - Selection
MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process - Selection SELECTION PROCESS Options Benefit Risk Cost Availability 1 2 3

MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process - Selection SELECTION PROCESS Procedure Benefit Risk Cost (PhP) Availability Options 1 most direct acceptable available 2 indirect acceptable available 3 indirect acceptable 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 Risk Cost (PhP) Availability Options 1 accuracy 99% acceptable available 2 accuracy 90% acceptable available 3 accuracy 50% acceptable 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 Risk Cost (PhP) Availability Options 1 yield greatest acceptable available 2 yield 90% acceptable available 3 yield 80% acceptable available Which is the most cost-effective procedure? Informed consent Option 1

Paraclinical Diagnostic Process - Interpretation
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!)

Paraclinical Diagnostic Process - Interpretation
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 A 3. H H

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 Papillary Carcinoma

NO NEED FOR PARACLINICAL DIAGNOSTIC TEST
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

Multiple Colloid Adenomatous Goiter
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

do thyroid function tests.
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.

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

NEED FOR PARACLINICAL DIAGNOSTIC TEST
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 and infection (negligible) PhP1000 Available Ultrasound Indirect exam <15% yield for ca Sound wave side effect (negligible) PhP800 Thyroid scan <12% yield for ca Radiation (minimal) PhP1200 Informed consent

FINE NEEDLE ASPIRATION BIOPSY vs
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

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 gelatinous substance in sample – COLLOID ADENOMATOUS NODULE

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) Colloid fluid with complete disappearance of mass – COLLOID CYST

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) 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

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

SELECTION PROCESS Options Benefit Risk Cost Availability 1 2 3

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

SELECTION PROCESS Treatment Benefit Risk Cost (PhP) Availability Options 1 SR1 = SR2 lesser available 2 SR2= SR1 more available Which is the more cost-effective treatment option? Informed consent Option 1

SELECTION PROCESS Treatment Benefit Risk Cost (PhP) Availability Options 1 as effective as 2 acceptable available 2 as effective as 1 acceptable available Which is the more cost-effective treatment option? Informed consent Option 2

MANAGEMENT OF A PATIENT PROCESS Application in Thyroid Disorders
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 - 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) Observation Potential of growing bigger with no medication No medications / operation side effects None Informed consent

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 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) Observation Potential of growing bigger with no medication No medications / operation side effects None Informed consent

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 Thyroidectomy 10-yr disease-free survival rate – 99% Hypothyrodism – 13% Permanent hypoparathyroidism – 0.3% Lower (anesthesia time) Available Total Thyroidectomy 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. Informed consent

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 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 Ref: Shaha A., Memorial Sloan-Kettering Cancer Center, Ann N Y Acad Sci. 2008 Sep;1138: Selective surgical management of well-differentiated thyroid cancer. MD Anderson Informed consent

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 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 Ref: National Comprehensive Cancer Network (NCCN) Guidelines Informed consent

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 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 Conflicting data Informed consent

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):

TREATMENT PROCESS Application in Thyroid Disorders For further reading: Thyroid Disorders - Indications for Surgery Clinical response of nodular colloid adenomatous goiters Joson RO. Philipp J Surg Spec 1998; 53(1):

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.

Management of a Patient Process Clinical Practice Guidelines
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
1985 Options Benefit Risk Cost Availability 2015

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

52th Postgraduate Course Theme Current Concepts and Management
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

Honor ATR 16th Chancellor Alfredo T. Ramirez Memorial Lecturer
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

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