Costs and Concerns in Cancer Care

Costs and Concerns in Cancer Care

ROJoson’s Thoughts, Perceptions, Opinions, and Recommendations

Every now and then, specially nowadays, we hear reports what seem to be major advances in the treatment of cancers.

If you look at the cost of treatment, it is usually very expensive.  Is it worth a try?

Ian Haines in 2016 wrote:

“In practice, many of the earlier targeted cancer drugs have turned out to be disappointing. They are only suitable for a limited number of patients, and only add, on average, a few months of survival.³

The clinical trials of new anticancer drugs use highly selected patients and the reported outcomes do not relate to the general community that we treat daily.⁴ For the benefits these drugs deliver, the costs seem excessive.^5,6 How are we to determine which new drugs are cost-effective and how do we pay for the ones that are?

Looking at cancer therapies approved by the US Food and Drug Administration (FDA) for solid tumours between 2002 and 2012, the prolongation in median overall survival was only 2.16 months.⁷ Of the 12 anticancer drugs approved by the FDA in 2012 alone, only three prolonged survival, two of them by less than two months. Yet nine were priced at more than $US10 000 per month.⁸

In metastatic colon cancer, the vascular endothelial growth factor (VEGF) inhibitor bevacizumab is used in many protocols. In Australia it costs up to $8000 per month and can be used indefinitely, but only increases average survival by 0.9 months.

Are the more recent expensive treatment worth taking a crack?

“The doctrine of justum pretium, or just price, refers to the ‘fair value’ of commodities. In deciding the relationship between price and worth (or value), the doctrine advocates that, by moral necessity, price must reflect worth. This differs from the function of free-market economies where prices reflect ‘what the market bears’, or what buyers are willing to pay.”

Are the more recent expensive treatment worth taking a crack?

FOR ME, NO. IF THEY WILL INCREASE THE AVERAGE MEDIAN SURVIVAL BY AT LEAST 5 YEARS, I MAY CONSIDER. IF NOT, NO. [ROJOSON’S TPOR].

ROJ@19aug11

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Costs and concerns in cancer care

Ian Haines, Associate professor¹ and Medical oncologist²

Aust Prescr. 2016 Oct; 39(5): 146–147.

Published online 2016 Oct 4. doi: 10.18773/austprescr.2016.056

Some recently developed anticancer drugs appear to be a major advance. In metastatic malignant melanoma a number of new immune checkpoint inhibitors have created excitement and hope in a disease for which there was previously no effective treatment.¹ One magazine hailed them as ‘the most revolutionary cancer treatment in decades’.² These targeted drugs are likely to have a major impact on the treatment outcomes for other advanced incurable cancers too, but they are very expensive.

In practice, many of the earlier targeted cancer drugs have turned out to be disappointing. They are only suitable for a limited number of patients, and only add, on average, a few months of survival.³

The clinical trials of new anticancer drugs use highly selected patients and the reported outcomes do not relate to the general community that we treat daily.⁴ For the benefits these drugs deliver, the costs seem excessive.^5,6 How are we to determine which new drugs are cost-effective and how do we pay for the ones that are?

Among patients with incurable metastatic melanoma 40–60% have BRAF V600 mutations and can be treated indefinitely with oral dabrafenib plus trametinib. The cost to the Pharmaceutical Benefits Scheme (PBS) is $8759 per drug per month ($17 518 per month total). Patients can then be started on an immune checkpoint inhibitor, such as pembrolizumab indefinitely at 2 mg/kg every three weeks, at a cost to the PBS of $8000 or more every three weeks, or $136 000 per year. These treatments may continue for years. Then patients can be given the cytotoxic immune modulator ipilimumab for a cost of $130 000 per course of four injections, which can be repeated if appropriate. These drugs can cost more than $500 000 per patient. None of these treatments are curative and on average they only prolong progression-free survival or overall survival by months, although some patients who would otherwise have died can have enduring benefit for years. There is no predictive biomarker for benefit from pembrolizumab or ipilimumab.

Looking at cancer therapies approved by the US Food and Drug Administration (FDA) for solid tumours between 2002 and 2012, the prolongation in median overall survival was only 2.16 months.⁷ Of the 12 anticancer drugs approved by the FDA in 2012 alone, only three prolonged survival, two of them by less than two months. Yet nine were priced at more than $US10 000 per month.⁸

In metastatic colon cancer, the vascular endothelial growth factor (VEGF) inhibitor bevacizumab is used in many protocols. In Australia it costs up to $8000 per month and can be used indefinitely, but only increases average survival by 0.9 months.

In 2015 a group of experts from the European Society for Medical Oncology said that many modern cancer drugs were of very little benefit to patients. They published a scoring system, unconnected with cost, that showed many drugs did not extend or improve people’s lives for very long.⁹

To address the cost of anticancer drugs there is a role for individual patients, organisations and physicians to advocate for greater access to, and fairer prices for, effective new therapies. The doctrine of justum pretium, or just price, refers to the ‘fair value’ of commodities. In deciding the relationship between price and worth (or value), the doctrine advocates that, by moral necessity, price must reflect worth. This differs from the function of free-market economies where prices reflect ‘what the market bears’, or what buyers are willing to pay.

Some European countries are achieving comparable or superior outcomes with less outlay by considering best practice and assessing cost-effectiveness.^10–12 Many governments like Australia’s are already using health-technology measurements for resource allocation. These often use cost-effectiveness thresholds like the National Institute for Health and Care Excellence in the UK which uses £20 000–30 000 per quality-adjusted year of life saved. Treatments exceeding this threshold are unlikely to be funded.

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ROJ@19aug11 

Thyroid Follicular Carcinoma with Bone Metastasis

19aug9

68 years old female

30-year duration of goiter

2-year duration of right tibial mass – biopsy done – follicular carcinoma

Total thyroidectomy

Intraoperative situation – as depicted in the following CT scan frames:

Tumor occupying entire left lobe, pushing trachea to the right and pushing left internal jugular vein to the lateral side.  No infiltration.

 

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ROJ@19aug9

Herpes Zoster – ROJoson’s Notes

August 8, 2019

Today, I saw a 22-year-old female patient with herpes zoster.

Herpes zoster is viral infection that occurs with reactivation of the varicella–zostervirus. It is usually a painful but self-limited dermatomal rash. Symptoms typically start with pain along the affected dermatome, which is followed in 2-3 days by a vesicular eruption.

I also had herpes zoster last December 31, 2018 to January 2019:

Herpes Zoster – ROJoson

Treatment can be conservative.  Watch and wait.  Analgesics. Clean wound daily.

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ROJ@19aug8

Cramps – ROJoson’s Notes

Cramps are involuntary muscle spasms or contractions.

They are usually sudden without clear cause and very severe.

Cramps can occur in the feet, legs, and hands.  I, ROJoson, have experienced all of these, particularly in 2019.  I am still  looking for the cause and ways on how to prevent this.

My theories at the moment: hypertensive medications (although cramps are reported as not common) and overused muscles especially on the hands (operation and typing).

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Today – August 8, 2019 – I saw a 31-year-old female patient with rheumatic heart disease who has been having continual cramps (every few seconds – unrelenting) on the left lower extremity since December 2018 (9 months now) and then on the left upper extremity since July 2019 (one month now).  Her 2-D echo showed left atrial thrombus. She had been prescribed Calcium and Magnesium with no response.  I suspect the rheumatic heart fever and thrombus are related to her cramps.  I pitied her as I saw her in severe pain.  I decided to help her admitted at the Philippine General Hospital through the help of my classmate, Dr. Rody Sy.

Cramps can also be caused by hypocalcemia secondary to hypoparathyroidism after a thyroid or neck surgery.

Prepping of Surgical Fields – ROJoson’s Notes

August 6, 2019

Lately, I have been using 70% ethanol for prepping of surgical fields.  I find it tedious to wipe out the povidone-iodine stain after an operation prior to dressing, particularly when I have to apply elastic bandage after a modified radical mastectomy.

I think starting July 4, 2019, I stopped using povidone-iodine for prepping for my MRM.

From July 4 to July 30, 2019, I have done this on 7 patients with no postop infection.

• Maaaachado
• Soooon
• Dooooogelio
• Hiiiiipos
• Saaaaalazar
• Maaaaasangkay
• Laaaandero

I also have used it for one thyroidectomy patient with no postop infection.

In the past 30 years, I have used ethnol 70% prep for minor surgical operation with no significant infection rate.

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18aug6

Occult Papillary Thyroid Cancer – A Case Report

Occult Papillary Thyroid Carcinoma Presenting with Bilateral Paratracheal Neck Masses – A Case Report and a Diagnostic Challenge

Emmeline Elaine L. Cua, MD, Rey Benjamin I. Joson, MD, Reynaldo O. Joson, MD, MSc Surg

2019

Abstract

A case of an occult papillary thyroid carcinoma presenting with bilateral paratracheal masses in a 71-year-old Filipino female with diagnostic challenges is being reported to raise awareness among Filipino physicians of this rare entity and also to promote efficient diagnostic approach.  The patient, with past history of pulmonary tuberculosis, presented with bilateral big nodular paratracheal neck masses, initially palpated to be bilateral nodular thyroid masses for which a multiple colloid adenomatous goiter was suspected.  However, after an ultrasound was done, the big nodular paratracheal neck masses turned out to be outside the thyroid gland and the thyroid gland was reported to have a 0.5 cm nodule on the upper pole of the right thyroid lobe.  A right papillary thyroid carcinoma with bilateral neck node metastasis was primarily suspected. Secondary clinical diagnosis was tuberculosis lymphadenopathy on the neck with a colloid adenomatous nodule on the right thyroid lobe.  A needle biopsy was done on the bilateral neck masses which revealed papillary thyroid carcinoma.  Intraoperatively, before proceeding to do a thyroidectomy, the thyroid gland was grossly normal with no nodule palpated which led to an uncertainty whether the preoperative diagnosis of thyroid carcinoma was correct.  However, on intraoperative evaluation of the bilateral neck masses, which grossly were lymph nodes, there was note of infiltration of the internal jugular veins. With preoperative needle biopsy of papillary carcinoma, an occult thyroid carcinoma with bilateral neck nodal metastases was thereby assumed.  A total thyroidectomy with bilateral modified neck dissections was done.  After the procedure, the whole thyroid gland was meticulously serially cut to look for occult thyroid carcinoma.  Two 1-mm whitish nodules each were seen on the medial aspects of the right and left thyroid lobes and one 4-mm whitish nodule on the isthmus.  All of these turned out to be thyroid microcarcinomas on histopathology.  The bilateral neck nodes also contained papillary thyroid carcinomas. The patient underwent adjuvant radioactive iodine therapy after the operation.

Keywords: Occult thyroid cancer, occult papillary thyroid carcinoma, papillary thyroid microcarcinoma

Introduction

Occult papillary thyroid carcinomas are primary thyroid cancers that are not clinically apparent.  To be considered occult, size of the primary papillary thyroid carcinomas if detected should be less than 1.0 cm (1-4) Some authors would set the upper limit at 1.5 cm (1, 5-7). However, majority set it at one cm or less.

The incidence of occult thyroid carcinomas has been reported to be 0.3% to 35% of all thyroid cancers (8, 9). The incidence of occult papillary thyroid carcinomas has been reported to be 7 to 25% of all papillary thyroid carcinomas (10, 11).

Lang (12), in 1988, in a sequence of 1,020 autopsies in a two-year period, found 63 or 6.2% occult thyroid cancers, the greatest diameters ranged between 0.5 and 10.5 mm. All but one of the 63 occult thyroid cancers were papillary type. Multicentricity was found in 46% and regional lymph node metastasis in 14%.

They are different kinds of clinical presentations of occult papillary thyroid carcinomas, one of which is with clinically apparent nodal metastasis where the cytologic or histologic diagnosis of papillary thyroid carcinoma in the metastatic foci leads one to suspect or to look for the occult carcinoma in the thyroid gland proper.  Such kind of presentation of occult papillary thyroid carcinoma is uncommon considering the overall incidence of occult papillary thyroid carcinomas of 6% (12) and reported incidence of concomitant regional lymph node metastasis ranging from 14% (12) to 17.8% (13, 14).

In the Philippines, there are no formal data and no published reports on the frequency of occult papillary thyroid carcinoma as well as on occult papillary thyroid carcinomas with nodal metastasis.

This paper reports on a Filipino patient presenting with bilateral paratracheal masses which turned out to be metastatic papillary thyroid carcinoma associated with 3 microcarcinomas in the thyroid gland proper.

The objectives of this reporting are one, to raise awareness among the Filipino physicians of such a possibility of bilateral paratracheal masses coming from microcarcinomas in the thyroid gland and two, to discuss the challenges faced by a clinician, especially the surgeon, in making efficient approach to diagnosis.

The Case

A 71-year-old Filipino female consulted in February 2019 because of neck masses which were noted four years prior.  There were no associated symptoms.  On initial examination, there were multiple non-fixated nodules, averaging 2-cm in size, at the right and left paratracheal areas spanning from the level of the thyroid cartilage to just above the clavicles.  On palpation, the multiple masses seemed to move with deglutition for which a thyroid disorder was suspected.  There were no masses in other parts of the body such as axillae and inguinal areas to suggest a lymphoma. There was a past history of treatment of pulmonary tuberculosis 15 years prior.  The primary clinical diagnosis given was multiple colloid adenomatous goiter. The secondary clinical diagnosis was tuberculous cervical lymphadenothies.

An ultrasound of the neck as well as chest radiograph were requested.  Chest radiograph showed infiltrates on the bilateral upper lung fields.  Ultrasound of the neck showed a 0.5 cm nodule on the upper pole of the right thyroid lobe with multiple bilateral neck nodes.  The thyroid nodule seen on ultrasound was not palpable.  With these additional data, the primary clinical diagnosis given was changed to thyroid carcinoma with bilateral neck node metastases. The secondary clinical diagnosis was tuberculous cervical lymphadenothies with colloid adenomatous nodule on the right thyroid lobe.

A needle biopsy was done on the neck masses. A sample was gotten on the right and another on the left. Results showed papillary carcinoma.  With the needle biopsy result, the pretreatment diagnosis was changed to occult papillary thyroid carcinoma with bilateral neck node metastases.  A neck exploration and possible complete thyroidectomy and bilateral modified radical dissection was planned.

On operation, after exposing the thyroid gland, it was meticulously palpated. The 0.5 cm right thyroid nodule reported on ultrasound was not palpated.  At this point in the operation, a question was raised whether an occult papillary thyroid carcinoma was the true diagnosis.  Exploration of the clinically palpable neck masses was done.  They were deemed to be lymph nodes located along the internal jugular veins. There were no hemorrhagic lymph nodes that were suggestive of papillary carcinoma nodal metastasis.  However, on both sides, some nodes were infiltrating the internal jugular veins.  With this intraoperative evaluation of the neck nodes, a diagnosis of occult papillary thyroid carcinoma with bilateral neck node metastases was maintained. A total thyroidectomy and bilateral modified radical neck dissection with excision of the walls of internal jugular veins that had tumor infiltrations were done.

Immediately after the operation, the whole thyroid gland was meticulously examined and sliced serially to look for occult papillary carcinoma or carcinomas.  A 4-mm cream white solid nodule was found on the isthmus and two 1-mm whitish solid nodules were each found on the medial aspect of the right and left thyroid lobes. (see Figs. 1 and 2)  The 0.5 cm right thyroid nodule was not found.

Histopathology report confirmed the findings of the multifocal papillary microcarcinomas, conventional and follicular variants, in the abovementioned areas.  The 0.5 cm nodule finding on ultrasound was not reported.  The bilateral neck nodes were reported to contain papillary carcinomas.

Patient underwent radioactive iodine therapy a month after operation.  She will be followed up for cancer surveillance.

Discussion 

The term “occult thyroid carcinoma” was used, for the first time, in 1955 (15).  It defined the thyroid cancer, with or without local metastases, which was identified after final histology (16).   

Occult thyroid carcinoma and occult papillary thyroid carcinoma have various definitions in the literature (1).

In 1997, Moosa and Mazzaferri defined “occult thyroid carcinoma” as an “impalpable thyroid carcinoma that is generally smaller than 1.0 cm” (2).   Stedman’s Medical Dictionary in 2006 defined “occult papillary carcinoma of the thyroid” as microcarcinoma of the thyroid or microscopic papillary carcinoma of the thyroid, usually well encapsulated and measuring less than 5 mm in diameter (17).

A combination is used in the World Health Organization classification system, where papillary thyroid microcarcinoma is defined as “papillary carcinoma measuring 1.0 cm or less in maximal diameter while other clinico-pathological features, such as metastasis to regional lymph nodes and/or distant organs as well as extrathyroid extension, are not considered” (3,4)

Shaha (5) and other authors (6,7) are using a broader definition for papillary thyroid microcarcinoma, 1.5 cm or less.  Majority of the authors, however, are using 1 cm and less for occult papillary thyroid carcinomas.   Recently, in 2018, Gong et al  (18) from China are proposing using 8 mm as the cut-off size for occult papillary carcinomas.  In an analysis of 1176 consecutive cases, they concluded that due to more aggressive behavior and poorer prognosis in larger tumor size (>8.5 mm), a tumor size ≤8.5 mm in diameter may be favorable to discriminate papillary thyroid microcarcinomas from papillary thyroid carcinomas and aid the selection of optimal management.

Occult thyroid carcinomas can be occult papillary and occult follicular carcinomas (19, 20).  Occult papillary carcinomas are more common than occult follicular carcinomas. The reported incidence of occult papillary carcinomas is 7 to 25% of all papillary thyroid carcinomas (10, 11) while that of occult follicular carcinomas is 3-4% (21, 22).

The terms occult thyroid carcinoma and papillary microcarcinoma could be considered synonyms in the majority of clinical situations (1,4).  This paper will focus on occult papillary thyroid carcinoma or papillary microcarcinoma.

They are different kinds of clinical presentations of occult papillary thyroid carcinomas (OPTC). Boucek (1)  mentioned four groups or categories.

The first group comprises patients with thyroid carcinoma or microcarcinoma incidentally found in the thyroid gland after total thyroidectomy for benign disease or at autopsy.

The second group comprises of patients with incidentally detected OPTC on imaging studies, mainly ultrasonography, and evaluated by fine needle aspiration biopsy (FNAB).

The third group comprises of patients with clinically apparent metastases of thyroid carcinoma, where the primary tumor is not detectable before surgery and microscopic tumor – microcarcinoma is found in the final histological specimen.

The fourth group comprises of patients with thyroid cancer localized in ectopic thyroid tissue with clinical symptoms or with apparent metastases.

Liu et al (23) proposed a fifth group which comprises of patients with clinical apparent metastases of thyroid carcinoma but the primary carcinoma could not be found by pathological examination of the thyroid gland.

There are no formal data on the relative frequencies of the four or five groups of occult thyroid papillary carcinoma.  Extrapolation from various current reports in the literature shows the first group to be the most common followed by the second then the third group. The fourth and fifth groups are not common.   The rampant use of ultrasonography and fine needle biopsy nowadays contribute to its second ranking in frequency.  In the third group with clinically apparent metastasis, neck node metastasis is more common than distant metastasis.

Woolner (16) n 1960 reported that of 140 occult papillary carcinomas treated surgically at the Mayo Clinic over a 30-year period, 58 were associated with nodal metastasis and 82 were found incidental to thyroid operations for other conditions.  None had distant metastasis.

Ito (9) reported in 2008 that between 1990 and 2004, 5400 patients underwent surgery for papillary thyroid carcinoma at Kuma Hospital, Japan. Seventeen (0.3%) were regarded as having occult papillary carcinoma. Clinically apparent node metastasis was detected in the lateral compartment in 16 patients and in the mediastinal compartment in 1 patient.

The patient in this case report belongs to the third group, one presenting with clinically apparent nodal metastasis which led to the discovery of the occult papillary thyroid carcinomas.

The patient initially presented as a diagnostic challenge when multiple paratracheal nodules were palpated in a background of being treated before for pulmonary tuberculosis.  The paratracheal masses, because of their adjacency to the trachea, moved with deglutition leading one to suspect multiple colloid adenomatous goiter (MCAG) as this is very common in the Philippines. Because of the past history of pulmonary tuberculosis, tuberculous cervical lymphadenopathy was a differential diagnosis.

After the ultrasound revealed the bilateral paratracheal masses were neck nodes rather than thyroid nodules but with a 0.5 cm nodule on the right upper thyroid lobe, the initial clinical diagnosis of MCAG was changed to thyroid cancer with bilateral neck node metastasis.  The result of fine needle aspiration biopsy which showed papillary carcinoma firmed up the second diagnosis which became the pretreatment diagnosis.

On initial intraoperative evaluation, the whole thyroid gland was grossly normal. The 0.5-cm nodule seen on ultrasound was not palpated.  These initial intraoperative findings presented another round of diagnostic challenge, questioning whether there was an occult carcinoma or not and whether a thyroidectomy should be done.  The surgeons proceeded to evaluate the paratracheal nodes.  The presence of infiltration of the bilateral internal jugular veins in the background of a needle biopsy result of papillary carcinoma led to the surgeons to make an intraoperative diagnosis of neck node metastasis from an occult papillary thyroid carcinoma.  Thus, the surgeons decided to do a total thyroidectomy and bilateral modified radical neck dissection with the plan to examine the thyroid gland closely after its removal.  The result of the closed examination of the removed thyroid gland showed three foci of  papillary microcarcinomas which were confirmed in the microscopic examination.

Conclusion

Reported is a case of a 71-year-old Filipino female presenting with bilateral paratracheal masses which turned out to be metastatic papillary thyroid carcinomas associated with 3 microcarcinomas in the thyroid gland proper. Approaches and challenges in clinical, paraclinical and intraoperative diagnoses were discussed. Careful intraoperative evaluation of the thyroid gland and the neck nodes plus a cytologic diagnosis of papillary carcinoma in the metastatic foci will facilitate diagnosis of an occult papillary carcinoma in the thyroid gland proper.  Total thyroidectomy followed by a meticulous examination of the gland is done to search for the occult papillary carcinoma in the thyroid gland proper.  The nodal metastases are treated accordingly, here a modified radical neck dissection was done.  After surgery, radioactive iodine treatment was given.

References

1. Boucek J, Kastner J, Skrivan J, et al. Occult thyroid carcinoma. Acta Otorhinolaryngol Ital. 2009;29(6):296–304.

2. Moosa M, Mazzaferri EL. Occult thyroid carcinoma. Cancer J 1997;10:180-8.

3. Hedinger C, Williams ED, Sobin LH. The WHO histological classification of thyroid tumors: a commentary on the second edition. Cancer. 1989;63:908–11.

4. Sobin LH, Wittekind C. TNM Classification of malignant tumours. 6^th edn. New York: Wiley-Liss; 2002.

5. Shaha AR TNM classification of thyroid carcinoma. World J Surg. 2007 May; 31(5):879-87.

6. Coleman SC, Smith JC, Burkey BB, et al. Long-standing lateral neck mass as the initial manifestation of well-differentiated thyroid carcinoma. Laryngoscope, 110 (2000), pp. 204-209.

7. Seven H, Gurkan A, Cinar U, et al. Incidence of occult thyroid carcinoma metastases in lateral cervical cysts. Am J Otol, 25 (2004), pp. 11-17.

8. Tüber L. Die epithelialen Formen der malignen Struma. Virchows Arch 1907;189:69-152.

9. Ito Y, Hirokawa M, Fukushima M, et al. Occult papillary thyroid carcinoma: diagnostic and clinical implications in the era of routine ultrasonography. World J Surg. 2008 Sep;32(9):1955-60.

10. Joshi P, Nair S, Nair D, Chaturvedi P.  Incidence of occult papillary carcinoma of thyroid in Indian population: case series and review of literature. J Cancer Res Ther. 2014 Jul-Sep;10(3):693-5.

11. Hwang CF, Wu CM, Su CY, Cheng LA. Long‐standing cystic lymph node metastasis from occult thyroid carcinoma: report of a case. J Laryngol Otol. 1992; 106: 932–4.

 

12. Lang W, Borrusch H, Bauer L. Occult Carcinomas of the Thyroid: Evaluation of 1,020 Sequential Autopsies. American Journal of Clinical Pathology, Volume 90, Issue 1, 1 July 1988, Pages 72–76.

13. DeLellis RA. Pathology and genetics of tumours of endocrine organs. World Health Organization classification of tumours, vol. 8, IARC Press, Lyon (2004), p. 64.

14. Cho JK, Kim JY, Jeong CY, et al. Clinical features and prognostic factors in papillary thyroid microcarcinoma depends on age. J Korean Surg Soc, 82 (2012), pp. 281-287.

15. Klinck GH, Winship T. Occult sclerosing carcinoma of the thyroid. Cancer 1955;8:701-6.

16. Woolner LB, Lemmon ML, Beahrs OH, Black BM, Keating FR, Jr. Occult papillary carcinoma of the thyroid gland: a study of 140 cases observed in a 30-year period. J Clin Endocrinol Metab 1960;20:89-105.

17. Stedman’s Medical Dictionary. Philadelphia, PA: Lippincott Williams & Wilkins; 2006 (accessed at http://www.stedmans.com).

18. Gong Y, Li G, Lei J, et al. A favorable tumor size to define papillary thyroid microcarcinoma: an analysis of 1176 consecutive cases. Cancer Manag Res. 2018;10:899–906.

19. Boehm T, Rothouse L, Wartofsky L.  Metastatic occult follicular thyroid carcinoma. JAMA. 1976 May 31;235(22):2420-1.

20. Nawarathna NJ, Kumarasinghe NR, Chandrasekera DN, Senevirathna RJ. Unusual presentation of occult follicular carcinoma of thyroid: As thoracic wall lump. Thyroid Res Pract 2016;13:36-9.

21. Shaha AR, Shah JP, Loree TR. Differentiated thyroid cancer presenting initially with distant metastasis. Am J Surg 1997;174:474-6.

22. Sevinc A, Buyukberber S, Sari R, Baysal T, Mizrak B. Follicular thyroid cancer presenting initially with soft tissue metastasis. Jpn J Clin Oncol 2000;30:27-9.

23. Liu H, Lv L, Yang K. Occult thyroid carcinoma: a rare case report and review of literature. Int J Clin Exp Pathol. 2014;7(8):5210–5214.

 

Fig 1. Thyroid after total thyroidectomy (center) and bilateral neck nodes.

Fig 2. Showing the microcarcinomas in the isthmus and medial aspect of the right and left thyroid  lobes.

 

 

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Links:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4056144/

Indian J Endocrinol Metab. 2014 May-Jun; 18(3): 410–413.

doi: 10.4103/2230-8210.131211

PMCID: PMC4056144

PMID: 24944940

Our experience with papillary thyroid microcancer

Anulekha Mary John, Paul M. Jacob,¹ Regi Oommen,² Sheila Nair,³ Aravindan Nair,¹ and Simon Rajaratnam

Medical Case Reports – ROJoson’s Notes

How to Make a Medical Case Report

A ROJoson’s Review

First posted: 19aug5

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A Case Report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of a patient. Case Reports may contain a demographic profile of the patient but usually describes an unusual or novel occurrence.

Category of Case Report

• An unexpected association between diseases or symptoms
• An unexpected event in the course of observing or treating a patient
• Findings that shed new light on the possible pathogenesis of a disease or an adverse effect
• Unique or rare features of a disease
• Unique therapeutic approaches
• A positional or quantitative variation of the anatomical structures

Ten Steps to Writing an Effective Case Report (Part 1)

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How to write a case report – ROJoson’s suggestions:

Format

Title:  

Authors:

Abstract

Keywords:  

Introduction

The Case

Discussion 

Conclusion

References

Make an initial rough draft.  May start with The Case or the Introduction, then Discussion, then Conclusion, and then Abstract.  Note down References to be used in the Introduction and Discussion.  Then, make the References.

Rewrite and rewrite and rewrite until comprehensively complete guided by the objective of the case report, until there is a rational sequence of the elements and paragraphs, and until the prescribed format of the targeted journal is complied.

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ROJ@19aug5

 

Branchial Cleft Sinus

2nd Branchial Cleft Sinus

19aug2

Excision

 

Many Viewers in Problem-based Learning in Surgery

Problem-based Learning in Surgery – Blog Site
19jul11
I had only 42 posts in this blogsite of mine since 2011. I was surprised to see a lot of viewers.

Resolutions: will post more in this blog site; will use it as my research arm from here on.

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ROJ@19jul11

Fracture of the Collar Bone or Clavicle

Trigger:

A 35-year-old male minimum wage earner had a motorcycle accident on June 27, 2019. He incurred a closed fracture of the middle third of the left collar bone or clavicle.  On July 11, 2019, a question was asked: what is the value-based or cost-effective treatment for him at this time – should he undergo an operative or surgical procedure or just conservative non-operative treatment with watch and wait stance?

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Objective of treatment: to facilitate healing of the clavicular fracture in the most cost-effective way possible.

Non-operative vs operative treatment?

Non-operative treatment

• Sling or figure-of-eight (prospective studies have not shown difference between sling and figure-of-eight braces)
• after 2-4 weeks begin gentle range of motion exercises
• strengthening exercises begin at 6-10 weeks
• no attempt at reduction should be made

Operative treatment

• Open reduction and internal fixation
• Rehabilitation or physical therapy

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Benefit- risk- cost -availability comparison

Benefit:

Non-operative:

• slower healing = operative (16.4 weeks) vs. non-operative (28.4 weeks)
• higher non-healing or non-union (especially if displaced) = 1 to 5% (but 95% will heal)

Operative:

• faster healing  = operative (16.4 weeks) vs. non-operative (28.4 weeks)
• lower incidence of non-healing or union

Risk:

Non-operative:

• Poorer cosmesis

Operative:

• Better cosmesis
• Surgical complications:
  • Pneumothorax
  • Air Embolism
  • Vascular Injury
  • Neurologic Injury
  • Hardware Complications
  • Need for further surgery

Costs

Non-operative:

• No operation costs – no costs of plates and screws

PhilHealth

23500 Closed treatment of clavicular fracture = 5,614  – 1,764 – 3,850

Operative:

• Operation costs – costs of plates and screws (cost of plates and screws – 12K to 30K; titanium – P30K)

PhilHealth

23515 Open treatment of clavicular fracture, w/ or w/o internal or external
fixation = 12,456 – 7,056 – 5,400

Availability:

Non-operative:

• Readily available – just sling and exercises
• No operation costs – no costs of plates and screws

Operative:

• Not as readily available because of operation costs – costs of plates and screws

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Treatment for a broken collarbone usually requires a sling or figure-of-eight splint to keep the area immobile for several weeks. In some cases, surgery may be required. Most clavicle fractures heal within 4 to 8 weeks. Physical therapy may help with rehabilitation.

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Approach Considerations

If all clavicle fractures are considered together, the vast majority heal with nonoperative management, which includes use of a simple shoulder sling. Studies have found, however, that in cases of specific fracture patterns and locations, not all clavicle fractures behave the same way.

The focus of treatment of middle third fractures remains nonoperative, although evidence is mounting, in support of operative treatment for displaced midshaft clavicle fractures. Management of medial clavicle fractures also has remained nonoperative.

The incidence of nonunion of displaced distal third fractures is high, and current recommendations are to fix these injuries surgically.

 

https://emedicine.medscape.com/article/92429-treatment

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Click to access ClavicleFractures.pdf

Patients with a completely displaced midshaft clavicular fracture may be counseled that they will be at a higher risk of sustaining nonunion and symptomatic malunion if the fracture is treated nonoperatively, but that there is no clear evidence that surgical treatment will improve their long-term function in general. They should also be counseled that, approximately 75% of the time, a completely displaced clavicular fracture that is treated nonoperatively will heal with few, if any, long-term consequences.
Complications of Open Reduction and Internal Fixation (ORIF)

• Pneumothorax
• Air Embolism
• Vascular Injury
• Neurologic Injury
• Hardware Complications
• Need for further surgery

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Non-operative treatment

• Sling or figure-of-eight (prospective studies have not shown difference between sling and figure-of-eight braces)
• after 2-4 weeks begin gentle range of motion exercises
• strengthening exercises begin at 6-10 weeks
• no attempt at reduction should be made

Operative treatment

• Open reduction and internal fixation
• Rehabilitation or physical therapy

Postoperative Rehabilitation

• early
  • sling for 7-10 days followed by active motion
• late
  • strengthening at ~ 6 weeks when pain free motion and radiographic evidence of union
  • full activity including sports at ~ 3 month

Outcomes

• time to union
  • operative (16.4 weeks) vs. non-operative (28.4 weeks)

https://www.orthobullets.com/trauma/1011/clavicle-shaft-fractures

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ROJ@19jul11