Metastatic Adrenocortical Carcinoma: Results of 56 Pulmonary Metastasectomies in 24 Patients
Jan op den Winkel, MD, Joachim Pfannschmidt, MD, Thomas Muley, PhD, Christiane Grünewald, MD, Hendrik Dienemann, MD, Martin Fassnacht, MD, and Bruno Allolio, MD
Departments of Thoracic Surgery and Translational Research Unit, Thoraxklinik am Universitatsklinikum Heidelberg, Heidelberg; and Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
Background. Surgical resection is an important form of treatment for metastatic disease in patients with adreno- cortical carcinoma (ACC). However, data about the re- sults of this treatment are sparse. We reviewed our experience with the resection of pulmonary lesions met- astatic from ACC as a means of evaluating such results.
Methods. A retrospective review of the database at a German national registry for ACC identified 24 patients (9 men and 15 women; median age, 41 years) who underwent pulmonary metastasectomy for primary ACC during the study period of 1989 through 2009. Only patients who met the criteria for potentially curative surgery, defined as the presumed feasibility of resecting all visualized tumorous lesions, were included.
Results. No perioperative deaths occurred in 56 pulmo- nary metastasectomies done on the patients in the study. The overall cumulative rate of 5-year survival, calculated from the time of first pulmonary surgery, was 24.5%, and the median survival was 50.2 months. Age younger than 41 years at the time of first pulmonary metastasectomy
and repeated pulmonary metastasectomy were associated with longer survival in a univariate analysis. In accord with this, we observed a median survival of 31.9 months in patients 41 years of age or older as compared with a median survival of 59.3 months in younger patients (p = 0.004). In patients with repeated pulmonary metastasec- tomies, median survival after the first resection was significantly longer, at 59.3 months than in patients who had only one pulmonary resection, whose median sur- vival was 31.9 months (p = 0.001).
Conclusions. We conclude that surgical resection of pulmonary metastases for ACC should be regarded as safe, with the potential for producing long-term survival in a highly selected group of patients. Younger patients may benefit more than older ones from such resection, and the recurrence of pulmonary metastases should not preclude repeated surgical resections of these lesions.
(Ann Thorac Surg 2011;92:1965-70)
@ 2011 by The Society of Thoracic Surgeons
A drenocortical carcinoma (ACC) is a rare disease, with approximately 0.5 to 2 cases per 1 million population per year occurring worldwide [1, 2-4]. The disease can present at all ages from infancy to the seventh or eighth decades of life, with a bimodal age distribution and peaks in the first and fourth decades.
Although surgery is the mainstay of treatment for ACC and represents the only chance for cure of the disease, most patients treated with radical resection (up to 80% in some series) [5] are still destined to experience relapse, often with metastases. Although the overall survival of patients with metastatic disease is poor, the long-term survival of such patients has occasionally been observed. A retrospective study of different tumor entities has proposed surgery as an effective treatment option for patients with isolated pulmonary metastases of ACC [6].
The present study represents the first contribution to the field of pulmonary metastasectomy for metastatic ACC, and was concerned with the outcome, long-term
results, and factors associated with prolonged survival in a contemporary series of patients who underwent pul- monary resection for metastatic ACC.
Patients and Methods
Between 1989 and 2009, 24 patients in 15 departments of thoracic surgery at centers in Germany and Austria underwent pulmonary resection of metastatic ACC, of whom 7 patients were in the Department of Thoracic Surgery at the University Hospital in Heidelberg, Ger- many. They were followed postoperatively and their clinical data were retrieved by the German Adrenocorti- cal Carcinoma Registry in Würzburg, Germany. This registry is a nationwide data base established in 2003 by the interdisciplinary German Adrenocortical Carcinoma Study Group, and contains detailed information on pa- tient demographics; symptoms at primary diagnosis; tu- mor characteristics; surgical, adjuvant, and palliative treatment modalities; and outcome [7]. The Ethics Com- mittee of the University of Würzburg, Germany, has approved the German Adrenocortical Carcinoma Regis- try as a source of clinical data in ACC. The retrospective
Accepted for publication July 29, 2011.
Address correspondence to Dr Pfannschmidt, Department of Surgery, Thoraxklinik Heidelberg, Amalienstrasse 5, D-69126 Heidelberg, Ger- many; e-mail: joachim.pfannschmidt@thoraxklinik-heidelberg.de.
| Age at pulmonary metastasectomy, median (range), years | 41 (20-73) |
| Sex | (n) |
| Male | 9 |
| Female | 15 |
| Lymph node involvement | |
| N+ | 5 |
| N- | 20 |
| Nx | 4 |
| Number of pulmonary metastases, median (range) | 2 (1-54) |
| Disease-free interval, median (range), months | 28.4 (0-160) |
study reported here was additionally approved by the Institutional Review Board of Heidelberg University, with the waiver of specific informed patient consent for inclusion in the study.
The study population consisted of 9 male patients and 15 female patients with a median age of 41 years (age range, 20 to 73 years) at the time of first pulmonary metastasectomy. Patient characteristics are given in Ta- ble 1. All 24 patients in the study received various systemic therapies (eg, mitotane) and 5 of the patients were given adjuvant radiotherapy for their primary tu- mors. Patients with a history of ACC and one or more pulmonary nodules were evaluated by physical examina- tion, chest radiography, chest computed tomography (CT), CT or magnetic resonance imaging (MRI) of the abdomen, or both, and in some cases also by bone scanning. In cases of indeterminate clinical or radiologic findings, further examinations (eg, 18-fluorodeoxyglu- cose-positron emission tomography) were performed to exclude extrapulmonary metastases.
The study was done only on patients who met the criteria for potentially curative surgery. The following criteria were considered indicative of a potentially cura- tive operation: (1) the metastases appeared to be techni- cally resectable, (2) the general and functional risks of surgery were considered tolerable, (3) the primary tumor was controlled, and (4) no extrathoracic lesions were detectable other than an isolated, technically resectable lesion. Patients were included as candidates for poten- tially curative surgery only if the histologic features of their pulmonary metastases were compatible with the histology of the primary lesion and were characteristic of pulmonary metastases of ACC. All patients were charac- terized retrospectively according to age and sex, number and type of pulmonary resections, number of pulmonary metastases, metachronous versus synchronous disease, infiltration of pulmonary or mediastinal lymph nodes, 30-day mortality, and overall survival. The endpoint for assessment of the effectiveness of treatment was death.
In total, 56 thoracic procedures were performed in the 24 patients who underwent pulmonary metastasectomy (Table 2). The surgical approach was chosen according to the location and number of pulmonary nodules as well as
the presence of synchronous intra-abdominal tumor or metastases. Lesions in patients with bilateral metastases were resected only through bilateral sequential thoracot- omy. Peripherally located nodules were resected thora- coscopically in 4 patients. Seven patients underwent combined thoracoabdominal surgery for simultaneous resection of their primary tumor or intra-abdominal metastases together with pulmonary metastases.
The resection procedures used for metastasectomy included wedge resection and various types of anatomic lung resections in selected cases (Table 2). Hilar and mediastinal lymph node dissection were performed con- currently with the initial resection of pulmonary metas- tases in 20 of the 24 patients in the study. A total of 34 surgeries were done for the initial resection for pulmo- nary metastases, consisting of 2 thoracoscopies, 4 thora- coabdominal surgeries and 28 thoracotomies, with 20 of the thoracotomies done through a bilateral sequential approach in 10 patients. Beyond these initial resections, 22 thoracic procedures were performed in patients with recurrent pulmonary metastases. These 22 repeat resec- tions were done in 10 of the 18 patients who presented with recurrent pulmonary metastases after the complete initial resection of ACC. Eight patients were ineligible for repeat surgery because of advanced metastatic disease.
Statistical Analysis
The study data were analyzed with SPSS version 17 for Windows (SPSS, Chicago, IL). Extrapolative analyses of survival according to potentially prognostic parameters were done by univariate analysis. The probability of survival was then analyzed according to the Kaplan- Meier method [8], using the date of pulmonary resection as the starting point. For patients who underwent bilat- eral sequential metastasectomy, the date of the second operation was used as the starting point. The log-rank test was used to calculate the significance of differences between subgroups. The relationship between single parameters in the test groups was calculated with Fish- er’s exact test [9].
Results
The 30-day postoperative mortality in the study was 0%, and no patient required repeat thoracotomy for postop- erative complications within the first 24 hours after initial metastasectomy. The mean period of follow-up of surviv- ing patients (censored patients) after the resection of a primary tumor was 109 months (range, 19 to 193 months), and after pulmonary metastasectomy was 63 months
| Type of Resection | Procedures (n = 56) | % |
|---|---|---|
| Wedge resection | 47 | 83.9 |
| Segmental resection | 3 | 5.4 |
| Lobectomy/bilobectomy | 5 | 8.9 |
| Pneumonectomy | 1 | 1.8 |
100
80
Survival (%)
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40
20
0
0 24 48 72 96 120 144 168
Months
At risk: 24 17 15 11 9 7 2 1 1 1 1 1 1 0
(range, 8 to 147 months). The cumulative 5-year survival of all of the patients in the study after resection of their primary tumors was 67%, with a median survival of 96.8 months, as compared with 24.5% after the first resection of pulmonary metastases (Fig 1). The median survival after pulmonary metastasectomy was 50.2 months. At the end of the study period, 11 patients were alive, but only 2 patients were disease-free, at follow-up intervals of 42 months and 7 months, respectively. None of the 13 deceased patients died of causes other than progressive ACC.
Of the prognostic factors analyzed in the study, sex, type of resection, number of metastases, synchronous versus metachronous metastatic disease, and lymph node involvement did not significantly influence sur- vival. However, univariate analysis revealed that re- peat pulmonary metastasectomy and age less than 41 years (which corresponded with the median age of the study population) were associated with improved sur- vival after metastasectomy. Figure 1 shows the actuar- ial survival curve for patients who underwent pulmo- nary metastasectomy.
Complete resection of pulmonary metastases of ACC was achieved after 52 operations in 20 patients, whereas in 4 patients only an incomplete resection (R1) was achieved. In 2 of these 4 patients incomplete resection followed the first repeat metastasectomy, in 1 patient it followed a second metastasectomy, and in 1 patient it followed a fourth pulmonary metastasec- tomy. Two of the 4 patients with incomplete resections were alive at follow-up intervals of 14.2 and 55.8 months, respectively, and two patients died at 39.6 and 40.6 months after surgery, respectively.
The number of pulmonary metastases in the study patients ranged from 1 to 54, with a median of 2 metas-
tases. The patient who had 54 synchronous metastases resected had undergone a first-step adrenalectomy for ACC followed by pulmonary metastasectomy through a bilateral sequential approach. The patient died of recur- rent hepatic and vertebral metastatic disease at 6 months after this metastasectomy. Overall, patients with multiple pulmonary metastases (n = 16) had a shorter median survival, of 50.2 months, than did patients (n = 8) with a solitary metastasis, whose median survival was 58.3 months, although this difference was not statistically significant (p = 0.75).
Pulmonary metastases were diagnosed synchronously with the primary ACC in 3 patients, one of whom had bilateral metastases. The median interval from resection of the primary ACC to the detection of pulmonary metastases was 28.4 months. Whether the onset of pul- monary metastases was synchronous or metachronous with the diagnosis of ACC seemed not to affect the prognosis.
Hilar and mediastinal lymph node involvement were analyzed through lymph node dissection in 20 patients, and lymph node metastases were found on histopatho- logic examination in 5 patients, in 2 of whom histopatho- logic examination revealed bilateral lymph node metas- tases. However, nodal status did not significantly influence survival.
Repeat thoracotomies for recurrent lung metastases were done in 10 patients. These patients had a signifi- cantly longer median survival, of 59.3 months, than did patients who had only a single pulmonary metastasec- tomy through a unilateral or sequential approach, among whom the median survival was 31.9 months (p = 0.001)
100
Cum. survival (%)
80
60
40
20
0
0
24 48 72 96 120 144 168
Survival time (months)
(Fig 2). Clearly this analysis is affected by a selection bias, in that only patients who survive have a chance for repeat surgery.
A predictor of shorter survival by univariate analysis was a patient age of 41 years or more at the time of pulmonary metastasectomy (n = 10), for which the me- dian survival was 31.9 months, as compared with 59.3 months for patients under 41 years of age (n = 14) (p = 0.004) (Fig 3).
Systemic therapy with mitotane was given before or after pulmonary metastasectomy to 23 patients. Of these patients, 9 received mitotane as monotherapy and the other 14 patients received it with combination chemo- therapy. The cytotoxic chemotherapy given to these latter 14 patients in addition to mitotane consisted of multiple drug combinations in various treatment regimens. Thus, doxorubicin plus cisplatin was given to 12 patients; etoposide, doxorubicin, and cisplatin were given to 10 patients; and streptozotocin was given to 5 patients. Sunitinib and carboplatin were given respectively to each of 2 patients as additional drugs, and 1 other patient was treated with the combination of gemcitabine and cape- citabine. A further patient, in whom ACC was first diagnosed in 1986 and who underwent 4 pulmonary metastasectomies between 1989 and 2000, was given only interferon and suramin.
Comment
Adrenocortical carcinoma is an uncommon and aggres- sive disease, and at the time of its diagnosis about one third of patients with ACC present with metastatic dis- ease [10]. Brennan and colleagues [11] have reported that
100
Cum. survival (%)
80
60
40
20
0-
0
24 48 72 96 120 144 168
Survival time (months)
At risk: Age<41y:14 1211 9 8 2 2 1 1 1 1 1 1 0 Age≥41y: 10 5 4 2 1 0 0 0 0 0 0 0 0 0
metastases occur in 70% of patients with ACC and most often involve the lungs (45%), liver (42%), lymph nodes (24%), and bone (15%). The 5-year survival of patients with distant metastases of ACC has been reported to range from 0 to 17% [12-14], with a median survival of less than 13 months [15-17]. An analysis of patients in the German Adrenocortical Carcinoma Registry, the cohort from which the reported study population was derived, indicated a similar poor prognosis for patients with stage IV adrenocortical carcinoma, whose 5-year survival was 17 % and whose median survival was 12.8 months [10]. Given the absence of options for curative systemic treat- ment in advanced ACC [18-21], surgical procedures for local recurrence or metastatic ACC are of considerable interest.
The present study was done to assess the outcome of a highly selected group of patients with pulmonary metas- tases of ACC who had undergone pulmonary metasta- sectomy, as well as in an attempt to identify prognostic factors associated with long-term survival in ACC. The study is the first investigation to focus specifically on pulmonary metastasectomy in ACC. Both the median survival (50.2 months) and the 5-year probability of survival (24.5%) of our study population, which consisted of patients eligible for pulmonary metastasectomy, are consistent with the survival data reported for three other series of patients in which the long-term outcome after resection of local and metastatic recurrent ACC was assessed [14, 16, 22], and compare favorably with the general survival in stage IV ACC [11-14].
In a study by Icard and associates [22] of 22 patients who underwent reoperation for local recurrence of ACC, the 5-year actuarial survival was 16% when calculated from the time of reoperation, and 28% for patients who underwent curative resection. Crucitti and coworkers [16] reported no operative mortality or morbidity from reop- eration for recurrent abdominal disease in 11 patients who underwent such surgery. The median survival of their patients was 42 months. In a study by Schulick and Brennan [14], resections of locally recurrent or distant metastases of ACC were performed in 47 patients. Pa- tients whose metastases were completely resected had a median survival of 74 months (5-year survival, 57%), whereas those with incomplete resection had a median survival of only 16 months (5-year survival, 0%). Among their patients who had complete resections, Schulick and Brennan could not find a statistically significant differ- ence in survival of those in whom resection was done for distant metastases (n = 21) and those in whom it was done for locally recurrent disease (n = 11). In our study, incomplete resection was not associated with an inferior outcome, probably because of the small number of pa- tients in this subgroup and the occurrence of incomplete resection only after repeat metastasectomy.
In our study, patients younger than 41 years of age had a significantly better prognosis than did patients older than 41 years. This may reflect a difference in tumor biology and a selection bias, in that younger patients are more likely to be considered for more aggressive treat-
ment in stage IV cancer and may better tolerate such treatment than do older patients.
It has been found that the time to recurrence of disease after resection of a primary tumor affects survival, with patients who have surgically resectable recurrences be- yond 24 months after surgery for primary ACC having a significantly longer survival than patients who experi- ence early relapse [23]. In the present study, however, the occurrence of synchronous versus metachronous disease did not significantly affect prognosis, again probably because of the small number of patients with synchro- nous disease.
Mediastinal and hilar lymph node involvement found during pulmonary metastasectomy is rarely examined in the literature [24, 25]. However, in the light of very recent data suggesting a better outcome in patients who have lymphadenectomy in the primary resection of ACC [26], the role of pulmonary or mediastinal lymph node dissec- tion or both is of special interest. In our study, 4 of 20 patients who underwent lymph node dissection had a diagnosis of pulmonary or mediastinal lymph node me- tastases or both. The median survival of patients in our study who had lymph node involvement was 59.3 months. It remains to be shown that systematic medias- tinal and hilar lymph node dissection can remove sub- clinical foci of tumor and influence long-term survival.
For many tumor entities, the long-term survival of patients who have undergone repeated thoracotomies for recurrent pulmonary metastases has not differed signifi- cantly from that of patients who have had only a single thoracotomy [27, 28]. In contrast, we found that patients with surgically resectable pulmonary recurrences of ACC had a better outcome than patients who underwent only a single thoracotomy. These results most likely represent a selection bias, in that patients who succumbed rapidly to their disease or who were no longer amenable to surgery because of rapid disease progression were no longer considered for repeated metastasectomy. The two groups most likely reflect different tumor biologies. Our observations indicate that a highly selective group of patients may benefit from repeated metastasectomy leading to survival, with this survival comparing favor- ably with that in stage IV ACC in general [1]. However, a randomized comparison of surgery for pulmonary me- tastases of ACC with alternative treatment strategies for these lesions would be needed to demonstrate a true advantage of metastasectomy, and such a comparison is highly unlikely to be available in the foreseeable future because of the rarity of the disease.
Despite its having involved the largest published series of patients undergoing pulmonary metastasectomy in ACC, the population in the present study involved only a small percentage of all patients being treated for ACC.
Our study has important limitations. Its retrospective design, limited number of patients, multi-institutional setting with patients treated by different surgeons, and lack of suitable controls limit our conclusions. However, the paucity of data regarding pulmonary metastasectomy in ACC makes our investigation a highly valuable start- ing point for further studies.
In summary, the surgical resection of pulmonary me- tastases of ACC can be regarded as safe, and is associated with longer-term survival in a highly selected group of patients. Patients younger than 41 years of age may have a more favorable prognosis than those older than this. Repeat thoracotomy for recurrent disease is compatible with long-term survival and is not associated with in- creased early mortality. Pulmonary metastasectomy should be considered for all patients with oligometastatic ACC and potentially completely resectable pulmonary metastases, and who have adequate pulmonary reserve.
One or two patients who underwent surgery at each of the following hospitals or clinics were included in our study: St. Marienhospital Vechta, Klinikum Konstanz, HSK-Hospital Wi- esbaden, University Hospital Köln, University Hospital Jena, University Hospital Berlin (Charité), University Hospital Leipzig, Leopoldina Hospital Schweinfurt, Klinikum Bremen Ost, University Hospital Tübingen, University Hospital Hom- burg/Saar, Hospital Löwenstein, Klinikum Osnabrück (all insti- tutions are located in Germany), and University Hospital Salz- burg (Austria).
References
1. Fassnacht M, Libe R, Kroiss M, Allolio B. Adrenocortical carcinoma: a clinician’s update. Nat Rev Endocrinol 2011; 7:323-35.
2. Kebebew E, Reiff E, Duh QY, Clark OH, McMillan A. Extent of disease at presentation and outcome for adrenocortical carcinoma: have we made progress? World J Surg 2006;30: 872-8.
3. Wajchenberg BL, Albergaria Pereira MA, Medonca BB, et al. Adrenocortical carcinoma: clinical and laboratory observa- tions. Cancer 2000;88:711-36.
4. Ng B, Lenert JT, Weksler B, Port JL, Ellis JL, Burt ME. Isolated lung perfusion with FUDR is an effective treatment for colorectal adenocarcinoma lung metastases in rats. Ann Thorac Surg 1995;59:205-8.
5. Terzolo M, Berruti A. Adjunctive treatment of adrenocortical carcinoma. Curr Opin Endocrinol Diabetes Obes 2008;15: 221-6.
6. Quiros RM, Scott WJ. Surgical treatment of metastatic dis- ease to the lung. Semin Oncol 2008;35:134-46.
7. Koschker AC, Fassnacht M, Hahner S, Weismann D, Allolio B. Adrenocortical carcinoma-improving patient care by establishing new structures. Exp Clin Endocrinol Diabetes 2006;114:45-51.
8. Kaplan E, Meier P. Non-parametric estimation from incom- plete observations. J Am Stat Assoc 1958;53:457-481.
9. Fisher R. Statistical Methods for Research Workers, ed. 12. Edinburgh: Oliver and Boyd, 1954.
10. Fassnacht M, Johanssen S, Quinkler M, et al. Limited prog- nostic value of the 2004 International Union Against Cancer staging classification for adrenocortical carcinoma: proposal for a Revised TNM Classification. Cancer 2009; 115:243-50.
11. Brennan MF. Adrenocortical carcinoma. CA Cancer J Clin 1987;37:348-65.
12. Bodie B, Novick AC, Pontes JE, et al. The Cleveland Clinic experience with adrenal cortical carcinoma. J Urol 1989; 141:257-60.
13. Icard P, Goudet P, Charpenay C, et al. Adrenocortical carcinomas: surgical trends and results of a 253-patient series from the French Association of Endocrine Surgeons study group. World J Surg 2001;25:891-7.
14. Schulick RD, Brennan MF. Long-term survival after com- plete resection and repeat resection in patients with adre- nocortical carcinoma. Ann Surg Oncol 1999;6:719-26.
15. Barzon L, Fallo F, Sonino N, Daniele O, Boscaro M. Adreno- cortical carcinoma: experience in 45 patients. Oncology 1997; 54:490-6.
16. Crucitti F, Bellantone R, Ferrante A, Boscherini M, Crucitti P. The Italian Registry for Adrenal Cortical Carcinoma: analy- sis of a multiinstitutional series of 129 patients. The ACC Italian Registry Study Group. Surgery 1996;119:161-70.
17. Pommier RF, Brennan MF. An eleven-year experience with adrenocortical carcinoma. Surgery 1992;112:963-71.
18. Hahner S, Fassnacht M. Mitotane for adrenocortical carci- noma treatment. Curr Opin Investig Drugs 2005;6:386-94.
19. Assie G, Antoni G, Tissier F, et al. Prognostic parameters of metastatic adrenocortical carcinoma. J Clin Endocrinol Metab 2007;92:148-54.
20. Berruti A, Ferrero A, Sperone P, et al. Emerging drugs for adrenocortical carcinoma. Expert Opin Emerg Drugs 2008; 13:497-509.
21. Fassnacht M, Kreissl MC, Weismann D, Allolio B. New targets and therapeutic approaches for endocrine malignan- cies. Pharmacol Ther 2009;123:117-41.
22. Icard P, Chapuis Y, Andreassian B, Bernard A, Proye C. Adrenocortical carcinoma in surgically treated patients: a
retrospective study on 156 cases by the French Association of Endocrine Surgery. Surgery 1992;112:972-80.
23. Fassnacht M, Allolio B. Clinical management of adrenocor- tical carcinoma. Best Pract Res Clin Endocrinol Metab 2009; 23:273-89.
24. Pfannschmidt J, Klode J, Muley T, Dienemann H, Hoffmann H. Nodal involvement at the time of pulmonary metastasec- tomy: experiences in 245 patients. Ann Thorac Surg 2006;81: 448-54.
25. Veronesi G, Petrella F, Leo F, et al. Prognostic role of lymph node involvement in lung metastasectomy. J Thorac Cardio- vasc Surg 2007;133: 967-72.
26. Reibetanz J, Jurowich C, Erdogan I, et al. Impact of lymph- adenectomy on the oncologic outcome of patients with adrenocortical carcinoma. Ann Surg, to be published.
27. Liebl LS, Elson F, Quaas A, Gawad KA, Izbicki JR. Value of repeat resection for survival in pulmonary metastases from soft tissue sarcoma. Anticancer Res 2007;27:2897-902.
28. Welter S, Jacobs J, Krbek T, Krebs B, Stamatis G. Long-term survival after repeated resection of pulmonary metastases from colorectal cancer. Ann Thorac Surg 2007;84:203-10.
Requirements for Maintenance of Certification in 2012
Diplomates of the American Board of Thoracic Surgery (ABTS) who plan to participate in the 2012 Maintenance of Certification (MOC) process as Certified-Active must hold an unrestricted medical license in the locale of their practice and privileges in a hospital accredited by the JCAHO (or other organization recognized by the ABTS). In addition, a valid ABTS certificate is an absolute re- quirement for entrance into the MOC 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 CME requirements are 150 Category I credits earned since January 1, 2008. At least half of these CME hours need to be in the broad area of thoracic surgery. Category II credits are not allowed. Interested individu- als should refer to the Board’s website (www.abts.org) for a complete description of acceptable CME credits.
Diplomates will be required to take and pass a secured exam after their application has been approved. Taking SESATS in lieu of the secured exam is not an option. The secured exam will be given from September 10 to Sep- tember 22, 2012, at Pearson Vue Testing Centers, which are located nationwide. Diplomates will have the oppor- tunity to select the day and location of their exam.
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The deadline for submitting an application for MOC is March 1, 2012; however, the Board will accept late appli- cations until April 15, 2012. A brochure outlining the rules and requirements for MOC in thoracic surgery is available on the Board’s website. For additional informa- tion, please contact the American Board of Thoracic Surgery, 633 N St. Clair St, Ste 2320, Chicago, IL 60611; telephone (312) 202-5900; fax (312) 202-5960; e-mail: info@abts.org.