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Ann Thorac Surg 2005;80:1231-1239
© 2005 The Society of Thoracic Surgeons

Original article: General thoracic

Endoscopic Ultrasound-Guided Fine-Needle Aspiration in Patients With Non-Small Cell Lung Cancer and Prior Negative Mediastinoscopy

Mohamad A. Eloubeidi, MD, MHS * , Ashutosh Tamhane, MD, MSPH, Victor K. Chen, MD, MSPH, Robert J. Cerfolio, MD

Department of Medicine, Division of Gastroenterology and Hepatology, and Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama

Accepted for publication April 1, 2005.

* Address reprint requests to Dr Eloubeidi, Endoscopic Ultrasound Program, University of Alabama at Birmingham, 1530 3rd Ave S, ZRB 636, Birmingham, AL 35294-0007 (Email: meloubeidi{at}uabmc.edu).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
BACKGROUND: Mediastinoscopy and endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) are complementary for staging non-small cell lung cancer (NSCLC) patients. We assessed (1) the yield of EUS-FNA of malignant lymph nodes in NSCLC patients with combined anterior and posterior lymph nodes that had already undergone mediastinoscopy and (2) the cost implications associated with alternative initial strategies.

METHODS: All patients underwent chest computed tomography (CT) and/or positron emission tomography (PET), and mediastinoscopy. Then, the posterior mediastinal stations (7, 8, and 9) or station 5 were targeted with EUS-FNA. The reference standard included thoracotomy with complete thoracic lymphadenectomy, repeat clinical imaging, or long-term clinical follow-up. A Monte Carlo cost-analysis model evaluated the expected costs and outcomes associated with staging of NSCLC.

RESULTS: Thirty-five NSCLC patients met inclusion criteria (median age 65 years; 80% men). Endoscopic ultrasound-guided FNA was performed in 53 lymph nodes in various stations, the subcarinal station (7) being the most common (47.3%). Of the 35 patients who had a prior negative mediastinoscopy, 13 patients (37.1%) had malignant N2 or N3 lymph nodes. Accuracy of EUS-FNA (98.1%) was significantly higher than that of CT (41.5%; p < 0.001) and PET (40%; p < 0.001). Initial EUS-FNA resulted in average costs per patient of $1,867 (SD ± $4,308) while initial mediastinoscopy cost $12,900 (SD ± $4164.40). If initial EUS-FNA is utilized rather than initial mediastinoscopy, an average cost saving of $11,033 per patient would result.

CONCLUSIONS: In patients with NSCLC and combined anterior and posterior lymph nodes, starting with EUS-FNA would preclude mediastinoscopy in more than one third of the patients. Endoscopic ultrasound-guided FNA is a safe outpatient procedure that is less invasive and less costly than mediastinoscopy.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Accurate preoperative staging is mandatory before therapy for patients with lung cancer because lymph node involvement (N2 ipsilateral or N3 contralateral disease) precludes curative surgery, directs therapy, and predicts long-term survival [1]. Unfortunately, metastatic cancer is found in 28% to 38% of non-small cell lung cancer (NSCLC) patients at the time of initial diagnosis [2–4]. Preoperative chemotherapy or radiotherapy, or both, before pulmonary resection may lead to improved survival in patients with metastatic NSCLC in N2 or N3 lymph nodes [5, 6]. Tissue confirmation of suspected malignant lymphadenopathy is required before surgical resection [7].

Current guidelines [1, 7–9] suggest that all patients with lymphadenopathy with lung cancer should undergo tissue sampling before undergoing surgical interventions. There are currently several invasive staging modalities that provide tissue sampling of suspicious mediastinal lymph nodes in patients with NSCLC [7, 8]. These include mediastinoscopy, video-assisted thoracic surgery (VATS), transthoracic fine-needle aspiration, transbronchial fine-needle aspiration (TBNA), and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). These techniques are often complementary as each has different access or approach to lymph nodes stations. Endoscopic ultrasound employs the esophagus as an acoustic medium to image the posterior mediastinum and adjacent lymph nodes. With the advent of curvilinear echoendoscopes that allow real-time imaging of the needle course, transesophageal sampling of mediastinal lymph nodes is possible [10, 11].

More recently, the role of EUS-FNA has been investigated as a minimally invasive technique for sampling mediastinal lymphadenopathy for patients with lung cancer and was found to have results superior to both positron emission tomography (PET) and computed tomography (CT) scan [10, 11]. When a clinician is faced with combined anterior and posterior lymphadenopathy, the presence of metastatic disease in the posterior mediastinum dictates the need for preoperative neoadjuvant therapy. Mediastinoscopy and EUS-FNA are complementary methods for tissue confirmation of enlarged mediastinal lymph nodes before surgical resection in NSCLC patients. In patients with combined anterior and posterior mediastinal lymphadenopathy, the choice of initial strategy to diagnose metastasis to ipsilateral (N2) or contralateral (N3) lymph nodes remains largely unknown.

Our primary objective was to assess the yield of EUS-FNA in evaluating NSCLC patients with lymphadenopathy, as identified by noninvasive imaging (eg, CT or PET scan) in both the anterior and posterior mediastinum, that previously had a negative mediastinoscopy. Our secondary objective was to perform a cost analysis comparing different initial tissue acquisition modalities (mediastinoscopy versus EUS-FNA) in evaluating patients with mediastinal lymphadenopathy.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Patient Selection
The Department of Gastroenterology at the University of Alabama at Birmingham prospectively maintains a database of all patients who undergo EUS and EUS-FNA. This Institutional Review Board–approved database was the primary source for selecting the patients for our study. During the study period (July 2000 to July 2004), 207 patients were referred for EUS for various indications of mediastinal diseases. Of these patients, 113 had lung cancer and underwent EUS for invasive lymph node staging. Biopsy-proven lung cancer patients were included in the current study if they underwent mediastinoscopy, prior to EUS, and had biopsy-proven benign lymphadenopathy in the anterior mediastinum (n = 35). Data on subject characteristics, type of lesion examined, location of primary tumor, and type of treatment received were recorded in this database. Data were also available on other staging techniques such as 18Fluoro-dexoyglucose positron emission tomography (FDG-PET) and CT scans. All patients were first imaged with thoracic CT scans. Twenty-nine patients also underwent FDG-PET scans. A FDG-PET scan was considered "positive" for a N2 lymph node if the PET scan revealed a hypermetabolic activity suggestive of malignant disease with a standard uptake value (SUV) greater than or equal to 2.5. A CT scan was considered "positive" if a lymph node was greater than or equal to 1.0 cm in the short axis. Positive lymph nodes were then numbered according to the revised TNM staging system [12].

EUS-FNA Technique
Endoscopic ultrasonography was performed under conscious sedation as previously described [10]. The endosonographer was aware of the presence of suspicious lymph nodes but was masked to the radiographs. A radial echoendoscope (GF-UM130; Olympus America, Melville, New York) was first used to evaluate the presence or absence of lymphadenopathy. The examination started by full evaluation of the left adrenal gland by imaging it from the fundus of the stomach. Then, the echoendoscope was gradually withdrawn to evaluate the inferior pulmonary ligament nodal region (station 9), the periesophageal areas (station 8), the subcarinal space (station 7), the aortopulmonary window (station 5), and pretracheal area (stations 2 and 4). Once a lymph node was identified, the radial echoendoscope was withdrawn, and a curvilinear echoendoscope (Olympus UC-30P or UCT 140) was then inserted and EUS-FNA of the target lesion was performed as previously described [10].

All EUS-FNA was performed using 22-gauge adjustable length Echotip needles (Wilson-Cook, Winston Salem, North Carolina). Cytologic diagnoses of the aspirated lesions were classified into four categories: (1) benign or reactive, (2) positive for malignancy, (3) atypical or suspicious for malignancy, or (4) nondiagnostic. The endosonographic criteria for malignant lymph nodes involvement were documented in all nodes before cytologic evaluation as previously described [10]. Criteria evaluated and documented included (1) size 1 cm or larger, (2) round shape, (3) homogeneous hypoechoic pattern and (4) sharp distinct borders [13].

A compound reference standard was used for the classification of the final diagnosis of the target lesion. In patients with benign lymphadenopathy, the determination was based on surgical-pathologic confirmation by thoracotomy or results of extended clinical follow-up of at least 6 months demonstrating the lack of clinical or radiologic disease progression. Patients with lung cancer and benign mediastinal lymphadenopathy underwent thoracotomy with complete thoracic lymphadenectomy. During mediastinal lymph node dissection, all nodes from each station were completely removed. Each node was numbered according to the revised TNM staging system [12]. In patients with malignant lymphadenopathy, the determination of the final status of the lesion was based on malignant cytologic results at EUS-FNA with a subsequent clinical course consistent with malignant disease or surgical exploration.

Immediate complications were assessed by the endosonographer. An experienced nurse contacted patients within 1 week, specifically inquiring about chest pain, fever, shortness of breath, and any symptoms perceived by the patient to be procedure-related.

All patients provided informed consent before all the procedures. This study was approved by the Institutional Review Board of the University of Alabama at Birmingham.

Statistical Analysis
Continuous variables were reported as mean with standard deviation and/or median with interquartile ranges (IQRs) while categoric variables were reported as proportions with respective percentages. We used Fisher's exact two-tailed test to compare two proportions; corresponding odds ratio (OR) and 95% confidence intervals (CI) were also reported. We determined the point estimates with 95% confidence intervals of operating characteristics (sensitivity; specificity; positive predictive value; negative predictive value; accuracy) of CT, PET, and EUS-FNA procedure. Significance for p value was predetermined at 0.05. The analysis was conducted using SAS statistical software (version 9.0; SAS Institute, Cary, North Carolina).

Cost-Analysis Methods
A Monte Carlo cost-analysis model [14] was constructed using Excel XP spreadsheets (Microsoft, Redmond, Washington) with supplemental software (XLSim; AnalyCorp, Palo Alto, California) to evaluate the expected costs and outcomes associated with staging of NSCLC in a hypothetical cohort of patients presenting with enlarged anterior and posterior mediastinal lymph nodes. The strategies evaluated were (1) initial mediastinoscopy; if negative, then followed by a subsequent EUS-FNA (initial mediastinoscopy); versus (2) initial EUS-FNA; if negative, then followed by a subsequent mediastinoscopy (initial EUS-FNA). The strategies evaluated are summarized in Figure 1.



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  		Fig 1. Cost-analysis of anterior mediastinoscopy versus endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) for tissue evaluation of mediastinal lymphadenopathy in non-small cell lung cancer (NSCLC) patients. *Note: if mediastinoscopy is the initial biopsy modality and a negative biopsy results, then EUS-FNA is performed as the alternative (subsequent) biopsy modality; if EUS-FNA is the initial biopsy modality and a negative biopsy results, then mediastinoscopy is performed as the alternative (subsequent) biopsy modality. (Gray circle = entry point of cost analysis; black circles = terminal points of cost analysis, where additional costs are not accrued.)

 
Monte Carlo simulation is a type of cost-analysis modeling that uses random numbers to capture the effects of uncertainty, to better reflect reality [14]. In the model, each patient has an outcome with associated costs and continues through the model accruing costs until an absorbing state is reached. The absorbing states in this model are (1) confirmation of mediastinal lymph node involvement by a biopsy method (mediastinoscopy or EUS-FNA) which precludes surgical resection, (2) two negative biopsy modality (mediastinoscopy and EUS-FNA) preceding surgical resection, and (3) death from complications from mediastinoscopy or EUS-FNA. Simulations are repeated for a set number of Monte Carlo times to determine a mean, standard deviation, and minimum and maximum values. Our decision analysis was run for a total of 10,000 simulations (theoretical patients) for each of the two strategies examined (initial mediastinoscopy and initial EUS-FNA).

The outpatient and inpatient costs involved in the lymph node staging of NSCLC patient with anterior and posterior mediastinal enlargement found on noninvasive imaging (eg, CT or PET scan) were based on 2004 Medicare standard allowable charges for current procedural terminology, diagnosis-related group, and ICD-9 codes. Additional costs were determined from review of the medical literature and analysis of costs from the University of Alabama at Birmingham Hospital. The costs utilized in our model are summarized in Table 1.


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  		Table 1. Summary of Costs (in 2004 US Dollars) Utilized in Cost-Analysis Model
 
Ovid Medline (1996 to November, week 2, 2004) was cross-searched with the following keywords: mediastinoscopy or endosonography, and non-small cell lung carcinoma; which returned 103 articles. When restricted to "human" and the English language and clinical relevance, 21 articles were retained [7, 8, 15–33]. Testing characteristics and complication rates of mediastinoscopy and EUS-FNA were derived from the medical literature, as described above. These values were converted to probabilities with which our theoretical cohort moved from one health state to another. Probability values vary in the medical literature, just as they do in reality and with different patients. Thus, a range of values, as found in the medical literature, rather then a discrete value, was incorporated into the cost analysis. Probabilities and transition values utilized in the cost analysis are summarized in Table 2. The costs and health outcomes were accrued until all the patients had reached an absorbing health state (death, thoracotomy, or lung resection) or after both mediastinoscopy and EUS-FNA results were negative.


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  		Table 2. Transitional Probabilities Utilized in Cost Analysis: Initial Mediastinoscopy Versus Initial EUS-FNA for Tissue Diagnosis of Lymphadenopathy in NSCLC Patients
 

   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
The study sample comprised 35 patients. The median age of the subjects was 64.5 years (Table 3). Eighty percent of the subjects were men. The most common location for the primary lung mass was left upper lobe or right lower lobe (each 31.4%). The median time from mediastinoscopy performance to EUS, performed as part of the initial staging, was 8 days (IQR, 6 to 14 days).


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  		Table 3. Subject Characteristics and Details of Primary Mass
 
In this cohort of 35 patients, 54 lesions were encountered. An EUS-FNA was performed in 53 lymph nodes in various American Thoracic Society stations (Table 4). One patient had a benign-appearing lymph node by EUS features, which was not sampled owing to intraprocedural patient oxygen desaturation. In 1 patient, no lymph nodes were detected. The subcarinal lymph node area (station 7) was the most common station (47.3%) evaluated by EUS-FNA; median long and short axes of lymph nodes were 18 mm and 11 mm, respectively (Table 4). All EUS-FNAs obtained adequate tissue for interpretation. Median number of passes to cytologic diagnosis was 3. One patient developed stridor immediately after the procedure but recovered uneventfully with conservative management. A nurse successfully contacted 63% of patients (22 of 35) within a week of the procedure to inquire about chest pain, fever, shortness of breath, or any symptoms perceived to be related to the procedure. Only 2 patients reported having self limited sore throat. Most of the patients seen in the thoracic surgery clinic within a month reported no complications.


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  		Table 4. Type and Characteristics of Lesions
 
Malignant lymph nodes were detected in 37.1% of patients (13 of 35; 95% CI: 21.5 to 55.1). The location of the primary mass was significantly associated with the presence of malignant lymph nodes (p = 0.03); lower lobe mass was more likely to have malignant lymph nodes as compared with upper lobe mass (OR = 6.8; 95% CI: 1.2 to 42.7).

The comparison of operating characteristics of EUS-FNA with CT and PET are shown in Tables 5 and 6. Go Computed tomography was done in 53 lesions, and PET was done in 45 lesions in different ATS lymph node stations. The EUS-FNA did not yield any false positive results whereas one false negative result was encountered. The accuracy of EUS-FNA in confirming malignancy in the mediastinal lymph nodes was 98.1% (95% CI: 89.9 to 100.0). Specificity, positive predictive value, and accuracy of EUS-FNA were significantly higher than for CT and PET scans (p < 0.001) whereas no significant difference was observed for sensitivity and negative predictive value.


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  		Table 5. Comparison of Operating Characteristics of EUS-FNA and CT
 

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  		Table 6. Comparison of Operating Characteristics of EUS-FNA and PET
 
All of the patients with positive (true positive) lymph nodes underwent combined chemotherapy and radiation therapy (Fig 2). Of the patients with negative lymph nodes (n = 20), 16 patients (80%) underwent surgery for the primary tumor. Three of these patients received postoperative chemotherapy or radiation therapy, or both, whereas 6 patients received preoperative chemotherapy or radiation therapy, or both. Three patients received chemotherapy or radiation therapy alone because their primary tumor was unresectable. Finally, an 81-year-old patient refused all forms of therapy and died 9 months after the procedure.



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  		Fig 2. Flow chart showing clinical management of patients according to the endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) cytology results. aIn patient 1, subcarinal lymph nodes were not biopsied owing to their benign features and development of oxygen desaturation; in patient 2, no posterior lymph nodes were detected. bOne of the patients was a false negative case (a mesothelioma case). (Chemo = chemotherapy; XRT = radiotherapy.)

 
Final diagnosis was confirmed by surgery in 45.7% of the subjects (16 of 35). Of the remaining 19 patients categorized by clinical follow-up, 7 died. Median follow-up for all the 35 patients was 219 days (IQR: 131 to 387). Of the 12 patients for whom final diagnosis was based on clinical follow-up, 4 had true negative lesions; median follow-up for these 4 patients was 205.5 days.

Cost-Analysis Results
This Monte Carlo cost analysis shows that initial EUS-FNA is more cost effective than initial mediastinoscopy when attempting to obtain tissue staging of mediastinal lymphadenopathy in NSCLC patients. Initial EUS-FNA resulted in average costs per patient of $1,867 (SD ± $4,308) while initial mediastinoscopy cost $12,900 (SD ± $4,164.4). If initial EUS-FNA is utilized rather than initial mediastinoscopy, an average cost saving of $11,033 per patient evaluated would result.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Staging lung cancer patients precedes therapy. Current guidelines suggest that all NSCLC patients with lymphadenopathy imaged by noninvasive tests should undergo tissue sampling before undergoing surgical interventions [1, 7–9]. Patients with lung cancer often present with lymph node enlargement at multiple levels or stations. The choice of initial procedure depends on the likelihood of findings disease in a certain location, safe accessibility by different modalities, and the availability and expertise with a certain technology.

Mediastinoscopy and EUS-FNA are two complementary tissue-sampling methods that facilitate lymph node staging of lung cancer patients. For instance, mediastinoscopy has excellent access to stations 2R, 4R, 2L, 4L, and the proximal 7, subcarinal stations, but cannot access the main or lower aspect of the subcarinal region (station 7). Standard mediastinoscopy cannot biopsy stations 5 or 6, aortopulmonary window lymph nodes. In contrast, EUS-FNA can easily access station 5 as well as the 7, 8, and 9 stations. Unlike mediastinoscopy, TBNA and EUS-FNA are usually performed on outpatient basis and have minimal morbidity. A recent study [34] compared EUS-FNA with TBNA in the evaluation of patients with suspected or confirmed lung cancer. Diagnosis of malignant mediastinal lymphadenopathy was superior for EUS-FNA compared with TBNA (92% versus 73%; p = 0.01). Endoscopic ultrasound-guided FNA was the most economical approach in patients with NSCLC with mediastinal adenopathy on CT as compared with TBNA or mediastinoscopy. This study and others [34, 35] suggested that when performed in patients with NSCLC and abnormal lymphadenopathy, EUS-FNA can reduce resource utilization. In addition, TBNA is underutilized even though bronchoscopy is more widely available than EUS-FNA [36].

Our study shows that in NSCLC patients with suspicious lymphadenopathy (identified by noninvasive imaging) in both the anterior and posterior mediastinum, starting with EUS-FNA would preclude mediastinoscopy in 37% of the patients. Endoscopic ultrasound-guided FNA is minimally invasive, is performed under conscious sedation, and has minimal risk in experienced hands. We also found that substantial cost savings can be achieved if EUS-FNA is used as the initial method of tissue sampling in mediastinal lymph nodes in patients with combined anterior and posterior mediastinal adenopathy.

While the introduction of PET scans resulted in improved staging accuracy for patients with lung cancer over CT scans, false positives remain significant [10]. A recent meta-analysis [9] of studies that included 1,045 patients with lung cancer showed a pooled sensitivity of 84%, specificity of 89%, positive predictive value of 79%, and negative predictive value of 93%. These results suggest that 21% of patients with "positive disease" by PET are falsely positive. Therefore, current guidelines suggest that patients with positive PET scan should undergo evaluation of abnormal stations by tissue acquisition [8]. In addition, we have previously reported [37] that FDG-PET is most often falsely negative in the subcarinal (station 7) and the aortopulmonary window regions (station 5). These stations are easily accessible by EUS-FNA.

In this investigation, we found that patients with lower lobe masses were more likely to have malignant lymph nodes in the posterior mediastinum especially in the subcarinal space compared with patients with upper lobe masses. This finding is consistent with the lymphatic drainage of the lung. This finding also has clinical relevance as EUS has superior accuracy to both CT and PET scans for the evaluation of the posterior mediastinum and is more sensitive in detecting the presence of malignant lymphadenopathy in these lymph node stations [4, 37–40].

Where does the role of EUS-FNA then fall in the evaluation of patients with lung cancer and mediastinal lymphadenopathy? Patients with either combined anterior and posterior lymphadenopathy or posterior lymphadenopathy alone or left adrenal enlargement should undergo EUS-FNA first [10, 41]. Patients with anterior lymphadenopathy alone are best served by mediastinoscopy (Fig 3). With the development of endobronchial ultrasound-guided FNA [42], it might be possible to sample anterior mediastinal lesions with this new technique. This technique is currently being investigated in tandem with EUS-FNA as a minimally invasive combined approach in patients with NSCLC 43].



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  		Fig 3. Algorithm for staging lung cancer patients using an endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA)–based approach.

 
We note the limitations of this study. All EUS-FNA were performed by a single experienced endosonographer and results might not be generalizable to private practice settings, where EUS is not widely disseminated. Secondly, we relied on a compound "gold" standard that utilized results obtained by EUS-FNA, surgical resection, and extended clinical follow-up. To date, no false positives EUS-FNA results from mediastinal lymph nodes have been reported in the literature. Furthermore, we felt that it was unethical to subject patients with malignant cytology by EUS-FNA to further invasive testing in order to verify a true positive result. Our methodology is similar to other investigations in the field [22, 31]. Of note, however, almost half of our patients underwent surgical resection confirming that our false negative results were negligible. Most of our patients enrolled in this study had enlarged mediastinal lymph nodes detected by other staging modalities such as PET and CT. We did not enroll patients in this study who had negative imaging by CT and PET. We are currently conducting such a trial. Moreover, a recent study has shown that EUS-FNA can detect advanced mediastinal disease and avoid unnecessary surgical exploration in almost 1 of 4 patients who have no evidence of mediastinal disease on CT scan [44]. Furthermore, while these patients were evaluated in a referral center for patients with lung cancer, and the study had a relatively small number of patients, these results are generalizable to all patients with enlarged combined anterior and posterior lymph nodes detected by imaging modalities such as CT and PET scans.

In conclusion, in patients with lung cancer and combined anterior and posterior lymphadenopathy, starting with EUS-FNA would preclude mediastinoscopy in more than one third of the patients. Cost analysis also identified initial EUS-FNA as a cost-saving alternative when compared with initial mediastinoscopy. These finding have major implications for resource utilization in NSCLC patients undergoing preoperative staging.

Requirements for Recertification/Maintenance of Certification in 2006
Diplomates of the American Board of Thoracic Surgery who plan to participate in the Recertification/Maintenance of Certification process in 2006 must hold an active medical license and must hold clinical privileges in thoracic surgery. In addition, a valid certificate is an absolute requirement for entrance into the recertification/maintenance of certification process. if your certificate has expired, the only pathway for renewal of a certificate is to take and pass the Part I (written) and the Part II (oral) certifying examinations.

The American Board of Thoracic Surgery will no longer publish the names of individuals who have not recertified in the American Board of Medical Specialties directories. The Diplomate's name will be published upon successful completion of the recertification/maintenance of certification process.

The CME requirements are 70 Category I credits in either cardiothoracic surgery or general surgery earned during the 2 years prior to application. SESATS and SESAPS are the only self-instructional materials allowed for credit. Category II credits are not allowed. The Physicians Recognition Award for recertifying in general surgery is not allowed in fulfillment of the CME requirements. Interested individuals should refer to the Booklet of Information for a complete description of acceptable CME credits.

Diplomates should maintain a documented list of their major cases performed during the year prior to application for recertification. This practice review should consist of 1 year's consecutive major operative experiences. If more than 100 cases occur in 1 year, only 100 should be listed.

Candidates for recertification/maintenance of certification will be required to complete all sections of the SESATS self-assessment examination. It is not necessary for candidates to purchase SESATS individually because it will be sent to candidates after their application has been approved.

Diplomates may recertify the year their certificate expires, or if they wish to do so, they may recertify up to two years before it expires. However, the new certificate will be dated 10 years from the date of expiration of their original certificate or most recent recertification certificate. In other words, recertifying early does not alter the 10-year validation.

Recertification/maintenance of certification is also open to Diplomates with an unlimited certificate and will in no way affect the validity of their original certificate.

The deadline for submission of applications for the recertification/maintenance of certification process is May 10 each year. A brochure outlining the rules and requirements for recertification/maintenance of certification in thoracic surgery is available upon request from the American Board of Thoracic Surgery, 633 N St. Clair St, Suite 2320, Chicago, IL60611; telephone: (312) 202-5900; fax: (312) 202-5960; e-mail: mailto:info{at}abts.org This booklet is also published on the website: www.abts.org


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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