Application of the Management Process in Thyroid Nodules: Thirty Years of Experience

16th Chancellor Alfredo T. Ramirez Memorial Lecture

UP College of Medicine – Philippine General Surgery Department of Surgery

Application of the Management Process in Thyroid Nodules: Thirty Years of Experience.

Reynaldo O. Joson, MD

September 7, 2016

Diamond Hotel, Manila

atr_lecture_16sept7_roj

Lecture and  Text of Slide Presentation

Thank you, Dr. Rodney Dofitas and Dr. Shiela de Robles for the heartwarming introduction.

Good morning.

Before anything else, I like to greet the Family of Dr. Alfredo T. Ramirez – Ms. Bella Yan-Ramirez and Mr. Clark Alfredo Ramirez

Greetings also to officers and members of Foundation for the Advancement of Surgical Education headed by Dr. Telesforo Gana; Department of Surgery headed by Dr. Nelson Cabaluna; and Postgraduate Courses Committee headed by Dr. Orlino Bisquera.

Surgical Colleagues, Surgical Learners, Friends, and Ladies and Gentlemen.  Good morning.

 

I like to say that it is indeed my honor to be selected this year to give the 16th Chancellor Alfredo T. Ramirez Memorial Lecture.

 

I am being given the privilege to give a lecture that will reflect on ATR’s dedication, excellence and contribution to Philippine Surgery.   A tall order indeed.

 

I like to start my task by first sharing with you my grateful memories of ATR to illuminate the his pioneering spirit, leadership and foresight in higher surgical education, postgraduate training and research.

 

In 1968, ATR started the Surgical Forum, a research contest among residents of the Department of Surgery of UPCM-PGH.  This is a memorabilia of the Surgical Forum Programme of 1977.

 

I joined the Surgical Forum from 1977 to 1979.  In the 1977 Surgical Forum, I presented 2 papers, namely, Tumors of the Parotid Gland and Carcinoid Tumors of the Gastrointestinal Tract.

 

In 1978, Early Surgery for Appendiceal Abscess and Management of External Gastrointestinal Fistulas.

 

In 1979, Problems and Rehabilitation of Filipino Stoma Patients.

 

The Surgical Forum gave me great learning opportunity to become a surgeon-researcher.  For this, I am thankful to ATR.

 

ATR as Chairman of the Department of Surgery always encouraged and motivated me to excel in being a medical educator.  This is a memorabilia of the ATR’s letter of commendation and encouragement in 1990 after teaching Year Level IV students.

 

Motivation and Encouragement Citation after teaching Year Level V students.

 

Letter of commendation and promotion to Assistant Professor IV in 1991.

 

With his encouragement and motivation, I obtained my Master in Health Profession Education in 1993.  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.

 

Thanks to ATR!

UPCM is the only institution offering MSc in Surgery in the Philippines!

By the way, we have three graduates of Master of Science in Surgery other than myself in the UPCM-PGH Department of Surgery. They are Dr. Carmela Lapitan, a Urologist; Dr. Glenn Genuino and Dr. Mel Anthony Cruz, both Plastic and Reconstructive Surgeons.

 

There you are my three grateful memories of ATR indeed illuminate his pioneering spirit, leadership and foresight in higher surgical education, postgraduate training and research.  Thank you, ATR.

 

Being chosen as the 16th Chancellor Alfredo T. Ramirez Memorial Lecturer is an honor and privilege.  In return, I like to honor ATR with a lecture that will hopefully reflect his dedication and excellence in medical education and research.  I will try my best.

 

The title of my lecture is Application of the Management Process in Thyroid Nodules: Thirty Years of Experience.

 

Actually, this topic and title was given to me by the Postgraduate Courses Committee.  It is supposed to make the ATR Memorial Lecture aligned to the theme of the Postgraduate Course.

 

But why thyroid and management process as specific topics, one may ask and I ask.

I just surmised my former students are so impressed with my usage of the patient management process which I formulated circa 1985 and the thyroid book which I wrote in 1986 (that’s 30 years ago) and which I have been using for the past 30 years as a basis in the management of patients with thyroid disorders or thyroid nodules.

 

The patient management process being referred to can be seen in this chart.

 

The elements of the process consist of the goals; interview; physical exam; clinical diagnostic processes; clinical diagnosis then advice; paraclinical diagnostic processes then advice; pretreatment diagnosis then advice;  selection of treatment options then advice; treatment and its results then advice; and lastly, advice on health maintenance and disease prevention.

 

Because of time constraint, I have decided to limit my discussion on the clinical diagnostic processes, paraclinical diagnostic processes; and selection of treatment processes.

 

The presentation template that I will use is to explain the processes and then give illustrations on their applications to thyroid disorders or nodules.  This will be in keeping with the title of my lecture – Application of Management Processes in Thyroid Nodules.

 

Management of a Patient is essentially and always a problem-solving and decision-making process with the following universal goals – resolution of the health problem in such a way that the patient is alive, with no complication, and with no disability and in such a manner that the patient is satisfied and there is no medicolegal suit.

 

As I said, the goals are universal. They apply to all patients, regardless of the nature of their health problem, thyroid disorders included.

 

Let’s now go to the clinical diagnostic processes.

 

We all know that the clinical diagnosis is derived from the data from history and physical exam or from symptom and sign data.  How do we process the data?  The processes that I recommend are pattern recognition and prevalence.

 

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

 

Knowing the common manifestations of  5 different diseases as follows:

Given a patient manifesting with pqrs, your diagnosis is Disease D.

The process used here is Pattern recognition or matching.  Isn’t it?

 

Knowing the common manifestations of 3 different diseases and relative frequency of each as follows:

Diseases A, B, and C have the same manifestations, but Disease C is the most common, say in the locality.

 

Given a patient manifesting with abcd, your diagnosis is Disease C.

The processes used here are Pattern recognition but mainly 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.

Is my observation correct?

My recommendation is to GO BEYOND CLINICAL CLASSIFICATION!

 

In this table, I listed 12 thyroid disorders that I have seen in my 30 years of practice in the Philippines.

 

9 out 12, that a majority, of the thyroid disorders can be clinically diagnosed with bases, meaning using pattern recognition and prevalence processes.  Only 3 are relatively difficult to diagnose – medullary carcinoma, follicular adenoma, and chronic thyroiditis.

 

Given a patient with diffuse goiter, PR less than 90/min, with no signs of malignancy, using pattern recognition and prevalence, the primary diagnosis should be diffuse colloid adenomatous goiter.

 

Given a patient with solitary thyroid nodule, not hard, solid / complex / cystic, PR less than 90/min, with no signs of malignancy, using pattern recognition and prevalence, the primary diagnosis should be colloid adenomatous nodule or colloid cyst.

 

Given a patient with multiple thyroid nodules, not hard, PR less than 90/min, with no signs of malignancy, using pattern recognition and prevalence, the primary diagnosis should be multiple colloid adenomatous goiter.

 

Given a patient with solitary thyroid nodule, hard solid, PR less than 90/min, using pattern recognition and prevalence, the primary diagnosis should be papillary carcinoma.

 

Given patient with solitary thyroid nodule, hard solid, no compression in the form of dysphagia and dyspnea, ipsilateral neck nodes, PR less than 90/min, using pattern recognition and prevalence, the primary diagnosis should be papillary carcinoma.

 

Given a patient with solitary thyroid nodule, lytic bone lesion suspicious for metastasis, no compression in the form of dysphagia and dyspnea, PR less than 90/min, using pattern recognition and prevalence, the primary diagnosis should be follicular carcinoma.

 

Given a patient with huge thyroid mass, with neck compression in the form of dysphagia and dyspnea, PR less than 90/min, elderly, using pattern recognition and prevalence, the primary diagnosis should be anaplastic carcinoma.

 

Given a patient with tender fluctuant mass, with no signs of malignancy, using pattern recognition and prevalence, the primary diagnosis should be acute thyroiditis or thyroid abscess.

 

Given a patient with nodular thyroid gland with no discrete mass, PR less than 90 / min, with no signs of malignancy, using pattern recognition and prevalence, the primary diagnosis should be chronic thyroiditis.  As I said earlier, this is relatively difficult to diagnose clinically.

 

Given a patient with diffuse goiter, PR more than 100 / min, sudden weight loss,  with or without exophthalmos, using pattern recognition and prevalence, the primary diagnosis should be hyperthyroidism.

 

Given a patient with diffuse goiter, PR less than 90 / min, short obese stature, with unusually slow body movement, using pattern recognition and prevalence, the primary diagnosis should be hypothyroidism.

 

There you are, I repeat:

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.

My recommendation is to GO BEYOND CLINICAL CLASSIFICATION!

 

My other recommendations are:

Rely more on pattern recognition as a priority than on prevalence but use both.

Rely more on physical characteristics of the thyroid lesion than on age and sex.

Here I listed down my writings on clinical diagnosis of thyroid disorders.  You can tap them online.

 

Let’s now go to the paraclinical diagnostic processes.

Do you need a paraclinical diagnostic procedure before treatment?

If yes, how do you select?

Then, how do you interpret the results?

 

The foremost indication for paraclinical diagnostic procedure is that you want to be more definite on your clinical diagnosis.

 

The data needed for processing for the indication of paraclinical diagnostic tests are the primary and secondary diagnosis or your differential diagnosis.

 

One has to quantitate the degree of certainty particularly on the primary diagnosis such as 60% to 99%.  The general rule to follow: If you are very certain or quite certain of your primary clinical diagnosis, you don’t need a paraclinical diagnostic procedure.  You can proceed to treatment.  The other thing to consider is to look at the treatment plan for the primary and secondary diagnosis particularly if you are not quite certain of your primary clinical diagnosis.  If the treatment plans are markedly different, as a rule, you go for a paraclinical diagnostic procedure.  If they are the same, you may not need a paraclinical diagnostic procedure.

 

Example or illustration:

If you are 98% certain of your primary clinical diagnosis and the treatment plan for the primary diagnosis is surgical and that of the secondary clinical diagnosis is non-surgical,  a paraclincal diagnostic procedure is not needed anymore unless there is strong reason to do so (example, a patient is insistent on having a 99.9% degree of certainty prior to treatment).

 

Another example or illustration:

If you are only 60% certain of your primary clinical diagnosis and the treatment plan for the primary diagnosis is surgical and that of the secondary clinical diagnosis is non-surgical, a paraclinical diagnostic procedure is definitely needed primarily because you are not certain of your diagnosis.

 

I will use this tickler to expound on the indication of paraclinical diagnostic procedure.

 

Which of the following statements is the strongest indication for a paraclinical diagnostic procedure?

  1. You can never be absolutely certain of your clinical diagnosis
  2. You want to confirm a clinical diagnosis which you are certain of
  3. You want to document a clinical diagnosis which you are certain of
  4. When you are not certain of your clinical diagnosis

 

My recommended answer is D – when you are not certain of your clinical diagnosis.

In A, it is a given there is no such thing as absolutely certain diagnosis.  If you use this reason, then all patients will need paraclinical diagnostic procedure.

In B,  if you have to confirm a clinical diagnosis which you are certain of, then all patients will need paraclinical diagnostic procedure.

In C – you document a clinical diagnosis which you are certain of only in a setting of a research.

Thus, the best answer is D – when you are not certain of your clinical diagnosis.  Do you  agree?

 

In the selection process of the paraclinical diagnostic procedures, once you have decided one is needed, construct a table that shows the options in the first column, comparative benefit, 2nd column, risk in the 3rd column, cost and availability in the 4th and 5th column.

 

Example or Illustration

An example of a constructed table of comparative data.

Looking at the comparative data, the most cost-effective will be Option 1, it being the one with the greatest benefit, acceptable risk, with almost comparable costing as the other options at P1000 and available.  Note: One can use this table to secure an informed consent.  Show this to the patient and let him choose.

 

Another example of a constructed table of comparative data.

Looking at the comparative data, the most cost-effective will be a choice between Option 1 and Option 2.  If 90% accuracy is acceptable, you may choose Option 2. If you need a higher accuracy and patient is willing to spend P5000, then the choice is Option 1.  Again, you can use this table to secure an informed consent.

 

Still another example.

The most cost-effective is option 1, it having the greatest benefit and at a cost similar to the second best.

 

In the interpretation process of the paraclinical diagnostic procedures, one has to correlate the results with the primary or secondary clinical diagnosis.  The general rule is if the result is congruent with primary or secondary clinical diagnosis, accept. If it is not, make a decision, either to accept or put on hold for a while.

 

I will use this tickler to expound on the interpretation of paraclinical diagnostic procedure.

 

Determine which paraclinical diagnosis should be accepted as the pretreatment diagnosis and which one should be put on hold for further decision-making.

 

  1. Paraclinical diagnosis is the same as the primary clinical diagnosis. ACCEPT!
  2. Paraclinical diagnosis is the same as the secondary clinical diagnosis ACCEPT!
  3. Paraclinical diagnosis is a clinical diagnosis least considered. HOLD
  4. Paraclinical diagnosis does not jibe with the clinical picture or diagnosis. HOLD.

 

When you say on hold, you can either repeat or do a different diagnostic procedures depending the circumstances.  Make a decision.

 

Application in Thyroid Disorders

 

There is NO NEED FOR ANY PARACLINICAL DIAGNOSTIC TEST in this case if based on pattern recognition and prevalence, you are very certain this is papillary carcinoma.

 

There is NO NEED FOR ANY PARACLINICAL DIAGNOSTIC TEST in this case if based on pattern recognition and prevalence, you are very certain this is follicular carcinoma.

 

There is NO NEED FOR ANY PARACLINICAL DIAGNOSTIC TEST in this case if based on pattern recognition and prevalence, you are very certain this is multiple colloid adenomatous goiter  The treatment will be same (total thyroidectomy) if it turns out to be something else other than multiple colloid adenomatous goiter.

 

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.)

 

Example of comparative data on options for paraclinical diagnostic procedures for thyroid nodules.

Suppose the options are needle biopsy, ultrasound, and thyroid scan.

Comparative data on benefit – direct exam with >90% yield for needle biopsy; indirect exam with less than 15% yield for cancer for ultrasound and thyroid scan;

Risk – pain and potential bleeding and infection for needle biopsy; practically none for ultrasound; radiation for thyroid scan

Comparative cost – P1000 for needle biopsy; P800 for ultrasound; P1200 for thyroid scan

All are readily available.

 

Present the data to the patient and let him choose.  If the patient asks you which is the best, which option would you recommend to the patient?  To be objective about it, you would choose Option 1 as it has a greatest benefit, negligible risk, with almost comparable costing as the other options and also available.

 

Suppose the patient does not want the pain of needle biopsy and radiation side effect of thyroid scan. He chose ultrasound instead.  You have to grant it to him.   This forms part of the informed consent.

 

At this point, allow me to say a few words on fine needle aspiration biopsy and the technique that I usually do.

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)

 

Using pattern recognition and prevalence processes, if I see dirty-white bits of tissues from a solid thyroid nodule on the glass slide, on needle evaluation, my primary suspect is PAPILLARY CARCINOMA.

 

If I see colloid gelatinous substance in the sample, my primary suspect on needle evaluation is COLLOID ADENOMATOUS NODULE.

 

If I obtain  colloid fluid followed with complete disappearance of mass, my primary diagnosis on needle evaluation is COLLOID CYST.

 

If I obtain pus from thyroid nodule on needle evaluation, my diagnosis is THYROID ABSCESS.

 

I therefore would like to stress the advantages of doing needle evaluation and aspiration biopsy rather than just fine needle aspiration biopsy.

Here I listed down my writings on needle evaluation of surface lumps and thyroid nodules in 1989.  If you are interested.

 

Let’s now go to treatment process, last topic.

 

The data one needs before the selection of treatment process include the following: the pretreatment diagnosis inclusive of its severity and stage and the goals and objectives of treatment.

 

In the selection process of the treatment procedures, construct a table that shows the options in the first column, comparative benefit, 2nd column, risk in the 3rd column, cost and availability in the 4th and 5th column.  The same that one construct in the selection process for paraclinical diagnostic procedures.

 

Example or Illustration

An example of a constructed table of comparative data.

Looking at the comparative data, the most cost-effective will be Option 1, it being the one with the greatest survival rate, acceptable risk, with almost comparable costing as the other options at P5000 and available.  Again, note that can use this table for an informed consent.

 

Another example or illustration

The more cost-effective option is definitely Option 1 as it carries lesser risk with the same benefit and cost.

 

Another example or illustration

The more cost-effective option is definitely Option 2 as it carries lesser cost with the other comparative data being equal.

 

Application in Thyroid Disorders

Example of comparative data

In the treatment of Grade I to 2 Colloid Adenomatous Nodule or Multiple Colloid Adenomatous Goiter

Options: Hormonal suppressive therapy, surgery, and observation

Comparative data on benefit:

Response rates for hormonal suppressive therapy: the range is 17% – 50% – 76%  (with 88% > 50% reduction); resolution of the mass in one sitting for surgery; potential of growing bigger with no medication.

Comparative data on risk: medication side effects for hormonal therapy; operation side effects for surgery; no side effects for observation.

Comparative data on cost:

PhP 11 / 100mcg tab (may take 12 months) at 2 tabs per day (P660 /month) = P7920 /year; P31,000 for surgery using PhilHealth Case Rate; none for observation

 

Present the data to the patient and let him choose.  This forms part of the informed consent.

If the patient asks you which is the best option, which would you recommend to the patient?  To be objective about it, I would choose Option 1 since I am dealing with a benign thyroid disorder, small one, and 88% will have more than 50% reduction.  One can control the size with hormonal therapy.

 

With a Grade III colloid nodule or multiple colloid adenomatous goiter, the situation will be different.  With the response rate with hormonal therapy being less than 5% as seen in this  example of comparative data, with the presence of cosmetic issue, one may have to recommend objectively to the patient surgery.   Even if surgery is outrightly recommended by the physician, I recommend comparative data among the different options be presented to the patient for understanding and informed consent.

 

Another example of application of the treatment process in thyroid disorder is seen in this table of comparative data on the outcome of treatment of papillary carcinoma, one lobe, no metastasis.  If one has these data from Cancer Institute Hospital of Tokyo, one would choose subtotal thyroidectomy over total thyroidectomy because of equal benefit, less complications, and less cost.

 

Still another example, comparative data from Memorial Sloan-Kettering Cancer Center on well-differentiated thyroid cancer, whether follicular or papillary, presented with these data, a patient and his physician would choose subtotal over total thyroidectomy because of equal survival rates, less complications, and less cost.

 

Still another example, comparative data from National Comprehensive Cancer Network, presented with these data, a patient and his physician who believe in the data, would choose total over subtotal thyroidectomy primarily because of better survival rate with total.

 

What do you do in case of conflicting data?

Give all data to patient and let him choose (informed consent) but assist him.  You can tell him your personal stand.  But try to be as objective as possible.  Respect the decision of the patient.

 

Here are my personal recommendations on thyroid nodule/s:

Operation – if malignant or 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.

 

Basis for my stand on benign nodules can be seen in this publication in 1998.

 

If you are interested in this writing of mine on indications for surgery, tap it online.

 

My personal recommendation on unilobar well-differentiated thyroid cancer with no nodes and 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.

 

There are 2 more important information that I like to share with you before I end my presentation.

 

Clinical care pathway consist of steps in patient management from diagnosis to treatment.

 

In the steps in patient management, one utilizes the management of a patient processes, the ones that I just discussed with you, clinical diagnostic processes, paraclinical diagnostic processes and treatment processes in problem-solving and decision-making and securing an informed consent.   Data and information from the clinical practice guidelines should be tapped as much as possible.  If data from clinical practice guidelines are not available or are conflicting, one can still proceed to do problem-solving and decision-making using the management of a patient processes.  Ultimately, what is most important is an informed consent on the shared decision by the patient and physician based on whatever data are available.

 

The second information that I like to share with you is that in 2015, NCCN started including the affordability into their guidelines.   30 years ago, I already included cost in my management of a patient process.  I hope, in the future, NCCN and other guidelines will also include availability which is also an important issue in decision-making.

 

With that, I end my memorial lecture.

 

I have explained the management of patient processes and I have illustrated their application in thyroid disorders.

 

I hope I have  aligned my lecture with the theme of this Postgraduate Course.

 

I sure hope that I have honored ATR with a lecture that reflects his dedication and excellence in medical education and research.
Thank you for your kind attention.

 

ROJ@16sept7

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