Hans-Stefan Hofmann

Objectives: In 2021, the German Federal Joint Committee (G-BA) introduced minimum volume regulations (MVRs) for the surgical treatment of lung cancer with the aim of improving quality of care through centralization. The present study aimed to evaluate the impact of this regulation on the development of lung cancer surgery in Germany. Methods: We performed a retrospective analysis based on the AOK (medical insurance) minimum volume transparency lists (2024–2026) and certification data from the German Cancer Society (DKG). Primary endpoint was the development of hospital locations according to MVRs. Secondary endpoints included the number of operations, the number of DKG-certified lung cancer centers (LCs), and the percentage of procedures performed in DKG-certified LCs. Results: Nationwide, the number of hospital locations fell by 19.6% between January 2022 and June 2025 following the implementation of the MVRs, while the number of anatomical lung resections increased by 11.3%. The proportion of procedures performed at hospital locations with ≥75 operations per year (≙MVRs) increased from 42.3% to 82.2%. The number of DKG-certified LCs went up by 24.2% (62 to 77), and the percentage of resections performed there went from 56.6% to 69%. Lastly, 17.8% of hospital sites still got a billing permission, even though they did not meet the MVRs. Conclusions: Implementation of the MVRs was associated with substantial structural centralization of lung cancer surgery in Germany, characterized by fewer hospital sites (−19.6%), increased surgical volumes (+11.3%), and a growing proportion of care delivered in DKG-certified LCs (+24.2%).

Background: Hyperthermic intrathoracic chemotherapy (HITOC) is an additive treatment option after surgical cytoreduction of pleural malignancies. Despite growing clinical experience and studies evaluating its feasibility, postoperative morbidity and mortality, as well as the effect on survival, there is still only little known about the local effects of HITOC on the lung parenchyma and tumour cells. The objective of this in vitro study was to evaluate the dose-dependent concentration and penetration depth of cisplatin in human lung tissue. Methods: In total, 40 patients were enrolled for elective lung resection, and wedge samples were taken to the laboratory. The visceral pleura was removed, and the decorticated lung tissue was incubated in cisplatin solutions of different concentrations (0.05, 0.075, and 0.1 mg/mL) at 42 °C over 60 min. Afterwards, platinum amounts in the lung tissue samples were measured using atomic absorption spectroscopy. Results: A strong decline of the cisplatin concentration was found until a depth of 3.5 mm, followed by a mild decline until a depth of 7.5 mm. In a depth of 0.5 mm, there was only a significant difference between 0.05 and 0.1 mg/mL (p = 0.03, Cohen’s d = 0.43). In a depth of 1.5 mm, there was an overall significant difference in cisplatin concentration dependent on dose (p = 0.027). In deeper tissue layers, no significant difference in cisplatin concentrations in the tissue was found. Conclusions: A dose-dependent increase of the cisplatin concentration was found for superficial tissue layers. This emphasises the relevance of sufficiently high intrathoracic concentrations of the chemotherapeutic agent. This study confirms that cisplatin penetrates lung tissue in therapeutically effective concentrations.

Background: Suspicious tumors of the lung require specific staging, intraoperative detection, and histological confirmation. We performed an intrathoracic, intraoperative contrast-enhanced ultrasound (Io-CEUS) for characterization of lung cancer. Methods: Retrospective analysis of prospectively collected data on the application of Io-CEUS in thoracic surgery for patients with operable lung cancer. Analysis of the preoperative chest CT scan and FDG-PET/CT findings regarding criteria of malignancy. Immediately before lung resection, the intrathoracic Io-CEUS was performed with a contrast-enabled T-probe (6–9 MHz—L3-9i-D) on a high-performance ultrasound machine (Loqic E9, GE). In addition to intraoperative B-mode, color-coded Doppler sonography (CCDS), or power Doppler (macrovascularization) of the lung tumor, contrast enhancement (Io-CEUS) was used after venous application of 2.4–5 mL sulfur hexafluoride (SonoVue, Bracco, Italy) for dynamic recording of microvascularization. The primary endpoint was the characterization of operable lung cancer with Io-CEUS. Secondly, the results of Io-CEUS were compared with the preoperative staging. Results: The study included 18 patients with operable lung cancer, who received Io-CEUS during minimally invasive thoracic surgery immediately prior to lung resection. In the chest CT scan, the mean size of the lung tumors was 2.54 cm (extension of 0.7–4.5 cm). The mean SUV in the FDG-PET/CT was 7.6 (1.2–16.9). All lung cancers were detected using B-mode and power Doppler confirmed macrovascularization (100%) of the tumors. In addition, Io-CEUS showed an early wash-in with marginal and mostly simultaneous central contrast enhancement. Conclusions: The intrathoracic application of Io-CEUS demonstrated a peripheral and simultaneous central contrast enhancement in the early phase, which seems to be characteristic of lung cancer. In comparison to preoperative imaging, Io-CEUS was on par with the detection of malignancy and offers an additional tool for the intraoperative assessment of lung cancer before resection.

Hyperthermic intrathoracic chemotherapy (HITOC) is an additional intraoperative treatment option within the multimodality therapy of pleural malignancies. A chemotherapy perfusion with high-dose cisplatin is performed over a period of 60 min after surgical cytoreduction to improve local tumour control through the eradication of residual tumour cells. Although HITOC is increasingly used, there is only little scientific evidence about the necessary safety measures after HITOC. Therefore, the objective of this study was an analysis of cisplatin excretion via various body fluids after HITOC, with the aim of providing recommendations on occupational health and safety. Five patients undergoing HITOC were included. Before and after the HITOC, as well as during the following days, serum, urine, and bronchial secretion, as well as pleural effusion, were sampled. The platinum levels in the samples were measured using ICP-MS (inductively coupled plasma-mass spectrometry). Immediately after the HITOC, the mean levels of cisplatin increased dramatically in the serum (from 0.79 to 1349 µg/L), urine (from 3.48 to 10,528 µg/g creatinine), and bronchial secretion (from 0.11 to 156 µg/L). Thereafter, the cisplatin levels dropped to 133 µg/L in the serum and 994 µg/g creatinine in the urine within nine days after the HITOC. The AUC ratio shows 59% of the cisplatin being excreted via the urine after 48 h. The sampling of pleural effusion started 24 h after the HITOC, and the cisplatin levels decreased from 618 to 93 µg/L within nine days. Although the cisplatin levels in the body fluids of HITOC patients are much lower compared to patients receiving intravenous chemotherapy, a significant amount of cisplatin is excreted via these body fluids. Consequently, safety precautions must be implemented in the post-HITOC care of patients to avoid occupational exposure to cisplatin.

Background: The intraoperative detection of solitary pulmonary nodules (SPNs) continues to be a major challenge, especially in minimally invasive video-assisted thoracic surgery (VATS). The location, size, and intraoperative frozen section result of SPNs are decisive regarding the extent of lung resection. This feasibility study investigates the technical applicability of intraoperative contrast-enhanced ultrasonography (Io-CEUS) in minimally invasive thoracic surgery. Methods: In this prospective, monocentric clinical feasibility study, n = 30 patients who underwent Io-CEUS during elective minimally invasive lung resection for SPNs between October 2021 and February 2023. The primary endpoint was the technical feasibility of Io-CEUS during VATS. Secondary endpoints were defined as the detection and characterization of SPNs. Results: In all patients (female, n = 13; mean age, 63 ± 8.6 years) Io-CEUS could be performed without problems during VATS. All SPNs were detected by Io-CEUS (100%). SPNs had a mean size of 2.2 cm (0.5–4.5 cm) and a mean distance to the lung surface of 2.0 cm (0–6.4 cm). B-mode, colour-coded Doppler sonography, and contrast-enhanced ultrasound were used to characterize all tumours intraoperatively. Significant differences were found, especially in vascularization as well as in contrast agent behaviour, depending on the tumour entity. After successful lung resection, a pathologic examination confirmed the presence of lung carcinomas (n = 17), lung metastases (n = 10), and benign lung tumours (n = 3). Conclusions: The technical feasibility of Io-CEUS was confirmed in VATS before resection regarding the detection of suspicious SPNs. In particular, the use of Doppler sonography and contrast agent kinetics revealed intraoperative specific aspects depending on the tumour entity. Further studies on Io-CEUS and the application of an endoscopic probe for VATS will follow.

Zusammenfassung: Der Trend zur Durchführung robotergestützter Operationen in der Thoraxchirurgie hat in den letzten 10 Jahren zugenommen. Die bekannten Vorteile der videoassistierten Thoraxchirurgie (VATS) im Vergleich zum offenen Zugang gelten auch für die Roboterchirurgie, ergänzt durch eine 3-D-Kamera, spezifische Instrumente mit großem Bewegungsumfang der Instrumentenspitze und eine ergonomische Konsole. Die Anwendung der Robotertechnologie bei thoraxchirurgischen Eingriffen hat sich als sicher und mit gleichwertigen onkologischen Ergebnissen erwiesen. Der Da Vinci-Roboter war das erste kommerziell erhältliche Robotersystem in der Chirurgie. In den letzten Jahren sind mehrere andere Robotersysteme auf den Markt gekommen. Im Aufbau und der Anwendung unterscheiden sich die aktuellen Robotersysteme. Das Ziel dieser Übersicht ist es, die aktuellen Systeme in der roboterassistierten Thoraxchirurgie (RATS) sowie zukünftige Entwicklungen bei RATS zu beschreiben.

40 000 to 60 000 people develop malignant pleural effusion (MPE) in Germany each year. The most common causes are lung cancer and breast cancer. Patients with pleural carcinomatosis have a median survival time of four months. We investigated the current health services situation regarding treatment with indwelling pleural catheters (IPC) versus talc pleurodesis (TP) in Germany based on registry data from the Federal Statistical Office, the Pleural Tumor Registry of the German Society for Thoracic Surgery, and the IPC registry of the ewimed GmbH company. In addition, we conducted a selective literature review on IPC and TP. The symptoms of dyspnea and thoracic pressure determine the need for therapy in MPE. Both TP and IPC are effective treatment options for MPE. Both therapeutic procedures are considered equally effective with respect to the relief of dyspnea, post-interventional quality of life, and complication rates. TP yields a higher rate of successful pleurodesis than IPC (relative risk: 1.56; 95% confidence interval: [1.26; 1.92]; p < 0.0001), while patients who receive an IPC stay in the hospital for a shorter time than those who undergo TP (a difference of slightly more than two days). The survival of patients with MPE is not affected by which of the two local therapeutic procedures is chosen. The indication for either IPC or TP needs to be determined individually for each patient on the basis of his or her general condition, symptoms, clinical situation („trapped lung“), and prognosis.

In the context of quality assurance, the objectives were to describe the surgical treatment and postoperative morbidity (particularly renal insufficiency). A retrospective, multicentre study of patients who underwent cytoreductive surgery (CRS) with cisplatin-based HITOC was performed. The study was funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation (GZ: RI 2905/3-1)). Patients (n = 350) with malignant pleural mesothelioma (n = 261; 75%) and thymic tumours with pleural spread (n = 58; 17%) or pleural metastases (n = 31; 9%) were analyzed. CRS was accomplished by pleurectomy/decortication (P/D: n = 77; 22%), extended P/D (eP/D: n = 263; 75%) or extrapleural pneumonectomy (EPP: n = 10; 3%). Patients received cisplatin alone (n = 212; 61%) or cisplatin plus doxorubicin (n = 138; 39%). Low-dose cisplatin (≤125 mg/m² BSA) was given in 67% of patients (n = 234), and high-dose cisplatin (>125 mg/m² BSA) was given in 33% of patients (n = 116). Postoperative renal insufficiency appeared in 12% of the patients (n = 41), and 1.4% (n = 5) required temporary dialysis. Surgical revision was necessary in 51 patients (15%). In-hospital mortality was 3.7% (n = 13). Patients receiving high-dose cisplatin were 2.7 times more likely to suffer from renal insufficiency than patients receiving low-dose cisplatin (p = 0.006). The risk for postoperative renal failure is dependent on the intrathoracic cisplatin dosage but was within an acceptable range.

A complete resection of thymic tumors is known to be the most important prognostic factor, but it is often difficult to perform, especially in advanced stages. In this study, 73 patients with advanced thymic tumors of UICC stages III and IV who underwent radical resection were examined retrospectively. The primary endpoint was defined as the postoperative resection status. Secondary endpoints included postoperative morbidity, mortality, recurrence/progression-free, and overall survival. In total, 31.5% of patients were assigned to stage IIIa, 9.6% to stage IIIb, 47.9% to stage IVa, and 11% to stage IVb. In stages III a R0 resection was achieved in 53.3% of patients. In stages IV a R0/R1 resection was documented in 76.7% of patients. Surgical revision was necessary in 17.8% of patients. In-hospital mortality was 2.7%. Median recurrence/progression-free interval was 43 months (p = 0.19) with an overall survival of 79 months. The 5-year survival rate was 61.3%, respectively. Median survival after R2 resection was 25 months, significantly shorter than after R0 or R1 resection (115 months; p = 0.004). Advanced thymic tumors can be resected with an acceptable risk of complications and low mortality. In stage III as well as in stage IV the promising survival rates are dependent on the resection-status.