Advances in percutaneous lung ablation: techniques, outcomes, and future directions—a literature review

Introduction

Rationale/background

Despite significant advances in screening and therapies, lung cancer remains the leading cause of cancer-related death worldwide (1). It is the second most commonly diagnosed cancer in both men and women, with an age-standardized cumulative lifetime risk of 3.8% in men and 1.8% in women (2). In addition to primary lung cancer, pulmonary metastases from extrapulmonary malignancies are both common and clinically significant. Approximately 20–54% of non-pulmonary cancers metastasize to the lungs, often with serious prognostic implications. For example, the 5-year survival rate for breast cancer drops from 96% to 21% with pulmonary spread, and for colorectal cancer, from 91% to 10% (3).

Local-regional control has been associated with improved survival in lung cancer patients, yet standard chemoradiotherapy often results in suboptimal local control (4). Non-small cell lung cancer (NSCLC) is broadly divided into early-stage and advanced disease. Early-stage disease typically includes stages I, II, and select IIIA cases, for which surgical resection is the preferred treatment (5). Similarly, metastatic disease is subdivided into oligometastatic and widely metastatic categories, with oligometastatic patients often considered for curative-intent resection (6). However, an aging population and rising comorbidity burden have led to a growing number of patients deemed inoperable. For these individuals, alternative local therapies such as stereotactic body radiotherapy (SBRT) and percutaneous ablation are increasingly utilized (7,8).

Percutaneous ablation is recognized by the National Comprehensive Cancer Network (NCCN) as an alternative treatment for medically inoperable but otherwise resectable lung cancer (6). The 2021 Society of Interventional Radiology (SIR) guidelines recommend ablation for patients with stage IA NSCLC, recurrent NSCLC, or ≤3 cm pulmonary metastases in the setting of oligometastatic disease (6). Similarly, the 2020 Cardiovascular and Interventional Radiological Society of Europe (CIRSE) endorses ablation for curative intent, treatment breaks (“chemoholidays”), and oligoprogressive disease (9). Given the overlapping indications with SBRT, the precise clinical role of ablation is still evolving. One scenario in which ablation may be preferred over SBRT is in patients with local recurrence after prior SBRT (10). Given these evolving indications and expanding clinical applications, a focused synthesis of the current evidence surrounding percutaneous lung ablation is warranted.

Objective

As percutaneous ablation becomes a more prominent tool in the management of early-stage and oligoprogressive lung disease, this manuscript aims to: (I) review the technical considerations for all major ablative modalities; (II) summarize clinical outcomes; (III) discuss post-procedural complications; (IV) compare ablation to other local therapies; and (V) explore emerging techniques and future directions in lung tumor ablation. We present this article in accordance with the Narrative Review reporting checklist (available at https://cco.amegroups.com/article/view/10.21037/cco-25-114/rc).

Methods

A narrative review of the literature was performed using PubMed, MEDLINE, major radiology and oncology journals, and reference lists from key manuscripts. Searches included combinations of free-text and MeSH terms related to lung tumor ablation, including “lung ablation, thermal ablation, microwave ablation, radiofrequency ablation, cryoablation (CA), bronchoscopic ablation, non-small cell lung cancer, oligometastatic, and local tumor control”. The search timeframe included studies published from January 1, 2000 through August 1, 2025, and the search itself was conducted on August 10–15, 2025.

Studies were included if they reported clinical outcomes, complications, technical considerations, or emerging technologies related to percutaneous lung ablation. Non-English publications, preclinical/animal studies, and abstracts without full text were excluded. Foundational mechanistic studies published prior to 2000 were included when historically relevant. As this is a narrative review, no formal systematic protocol, dual screening, or quantitative synthesis was performed.

A summary of the search strategy is provided in Table 1.

Technical overview

Patient selection and pre-procedural workup

A critical component of patient selection for lung tumor ablation is the thorough review of pre-procedural imaging. All patients should undergo a contrast-enhanced chest computed tomography (CT) to assess tumor size, vascularity, and proximity to adjacent structures such as the mediastinum, pleura, and diaphragm. These anatomic relationships inform both the feasibility of ablation and the optimal choice of modality.

The maximum treatable tumor size depends on the clinical context. For primary lung tumors treated with curative intent, lesions up to 3 cm—the upper limit of stage IA NSCLC—are generally considered ideal (5,11). However, some studies have reported survival benefit with ablation of tumors up to 5 cm, including in select patients with stage IIA disease (11,12). In the oligometastatic setting, a commonly accepted threshold is 3.5 cm (13).

In planning the procedure, it is essential that the ablation zone encompasses the tumor plus an adequate margin. While a 1 cm margin is typically targeted, margins as small as 2 mm may be sufficient in certain anatomical locations (14,15).

Patient medical history, particularly pulmonary function, should be carefully evaluated. Although lung ablation is generally well tolerated, heat-based modalities [e.g., radiofrequency ablation (RFA), microwave ablation (MWA)] may result in a transient decline in pulmonary function, which can be clinically significant in compromised patients (16). For this reason, some interventionalists favor CA in patients with limited pulmonary reserve or tumors near critical structures, given its lung-sparing effect and ability to preserve tissue architecture (17). Regardless of modality, baseline and post-procedural pulmonary function testing is recommended to guide treatment planning and assess physiologic impact.

Ablation modalities

Currently, there are three main modalities used in the lung for tumor ablation. They include RFA, MWA and CA. Specific details can be found in Table 2.

RFA

RFA is the oldest of the thermal ablation modalities. It uses an alternating electrical current of approximately 400 kHz applied through an ablation probe, with the current exiting via a grounding pad. This generates tissue temperatures above 55 °C, leading to coagulative necrosis and protein denaturation (18-20). However, RFA has notable limitations. Charred tissue can impede current flow, resulting in uneven heating. The “heat-sink effect”, where heat dissipates into nearby blood vessels, may reduce treatment efficacy. Additionally, the grounding pads can cause skin burns (20).

MWA

MWA, though also a heat-based technique, offers several advantages over RFA. MWA generates heat by emitting an electromagnetic field—typically 915 or 2,450 MHz—from dipoles at the probe tip. This field agitates hydrogen molecules in the tissue, creating heat (19-22). Unlike RFA, MWA does not rely on thermal conduction, allowing for faster heating, larger and more uniform ablation zones, and less susceptibility to the heat-sink effect. Furthermore, because MWA does not require a grounding pad, there is no associated risk of skin burns (21,23).

CA

CA is the most recent of the three modalities and uses cold rather than heat for tissue destruction. It operates by forcing high-pressure argon gas through the probe, which then expands, absorbing heat from surrounding tissues via the Joule-Thomson effect (20). This results in tissue temperatures as low as −170 °C near the probe, gradually increasing toward the periphery (24). Cell death occurs at temperatures below −20 °C, with −40 °C generally targeted for effective ablation (25). CA offers several advantages: preservation of tissue architecture, visualization of the ice ball during the procedure, reduced heat-sink effect, and a theoretical immunologic benefit known as the abscopal effect. However, it may carry a risk of incomplete ablation if target temperatures are not achieved (17,20).

Procedural techniques

Regardless of the ablative modality, CT guidance is required for probe placement, whether with conventional CT, CT fluoroscopy, or cone beam CT (CBCT). While CT fluoroscopy increases radiation exposure to the operator, it allows for real-time probe manipulation, particularly useful when targeting small lesions or lesions near critical structures (11,26). CBCT may offer additional advantages when out-of-plane needle placement is necessary (27).

Anesthesia is another critical technical consideration. Although lung ablation can be performed with local anesthesia or moderate sedation, general anesthesia is generally preferred. This is due to the potential for significant pain, anxiety, and procedural length, which may be poorly tolerated under lighter sedation. General anesthesia also allows for temporary lung immobilization and provides airway protection should pulmonary hemorrhage occur.

Antibiotic prophylaxis varies by institution, but agents such as amoxicillin-clavulanate or ofloxacin have been reported (11,28).

Needle placement strategy depends largely on the ablation modality. For MWA, the goal is typically central placement of the antenna within the lesion. A single probe is usually adequate for lesions under 3 cm (29). For larger lesions (>3 cm), either a larger gauge antenna (e.g., 14G) or multiple antennas (two or three) may be required (29,30). Ablation times vary depending on the device, energy settings, and lesion size. Manufacturer-recommended protocols have been applied accordingly; for example, Covidien microwave antennas using 35–45 W generators typically require 5–10 minutes of ablation time (31). In contrast, with higher-energy MWA systems, median ablation times as short as 2 minutes have been reported (30,32). Figure 1A-1D demonstrates examples of MWA.

Figure 1 A 48-year-old female with metastatic breast cancer undergoing MWA of a solitary 7 mm RLL lung nodule. (A) PET-CT demonstrates a hypermetabolic right lower lobe lung nodule (circle). (B) Neuwave ablation probe (arrow) inserted via a lateral-to-medial approach. Ablation was performed at 65 W for 2 minutes, followed by a second ablation at 65 W for 1 minute. (C) Intraprocedural CT demonstrates edema and/or hemorrhage within the ablation zone (circle). (D) PET-CT at 3 months post-ablation shows no residual hypermetabolism at the ablation site (circle), consistent with complete response. CT, computed tomography; MWA, microwave ablation; PET, positron emission tomography; RLL, right lower lobe.

For CA, while a central approach is possible, many advocate for a bracketing technique, placing probes around the lesion’s periphery. A common guideline is one cryoprobe per centimeter of tumor diameter. Various CA protocols exist; a frequently used regimen includes:

• 3-minute freeze;
• 3-minute passive thaw;
• 8-minute freeze;
• 5-minute passive thaw;
• 8-minute final freeze.

Protocols may be adjusted based on intra-procedural imaging of the ice-ball. CT monitoring ensures the ice-ball encompasses the lesion with at least a 1 cm margin and allows surveillance for complications like pneumothorax, hydrothorax, or hemorrhage (11). Figure 2A-2E demonstrates an example of lung tumor CA.

Figure 2 A 69-year-old woman with enlarging left upper lobe squamous cell carcinoma treated with percutaneous cryoablation. (A) PET-CT reveals a 2.7 cm × 1.8 cm hypermetabolic left upper lobe mass (arrow). (B) First of two intraprocedural CT-guided cryoprobe placements (“1”). (C) Second intraprocedural probe placement targeting the posterior aspect of the lesion (“2”). (D) Immediate post-procedural CT following a triple-freeze protocol (3-min freeze, 3-min thaw, 8-min freeze, 5-min thaw, 8-min freeze, 4-min passive thaw) shows residual intraparenchymal ice at the treatment site (circle). (E) Six-month follow-up PET-CT shows post-treatment cavitation (circle) without residual metabolic activity, consistent with complete response. CT, computed tomography; PET, positron emission tomography.

Special considerations apply when ablating lesions near critical structures. CA may be favored due to better visualization of the ice-ball and potentially improved tolerance near mediastinal structures. Additionally, hydrodissection or intentional pneumothorax can be used to create a protective buffer between the probe and adjacent structures like the mediastinum or chest wall. However, the pleural space has limited capacity for fluid compared to the peritoneum, necessitating careful technique to avoid over-distension or inadvertent mediastinal infiltration (33).

Clinical outcomes

Primary lung cancer

Several studies have evaluated both local tumor control (LTC) rates and overall survival (OS) for the three main ablation modalities in treating early-stage NSCLC, with some variation in outcomes (34). An overview of LTC and OS for each ablative modality can be found in Table 3.

LTC

CA has demonstrated the most favorable LTC rates among the ablation modalities, though data remain limited due to its more recent adoption. Reported 1-, 2-, and 3-year LTC rates for CA are approximately 91%, 87%, and 85%, respectively (35). MWA generally outperforms RFA with reported 1-, 2-, and 3-year LTC rates ranging from 73–96%, 65–80%, and 24–72% for MWA, compared to 73–77%, 55–62%, and 42–64% for RFA (35-37). SBRT appears slightly superior to all three ablation modalities, with LTC rates of 96–98%, 86–90%, and 85–88% at the same intervals (34).

OS

Survival comparisons are more challenging due to heterogeneity in patient populations and study designs. For RFA, reported 1-, 2-, and 3-year OS rates are 85–89%, 53–56%, and 32–41%. MWA shows highly variable outcomes—possibly due to its broader application in tumors of varying sizes—with reported survival rates ranging from 79–100% at 1 year, 35–92% at 2 years, and 16–50% at 3 years (34-37).

CA may offer a survival advantage over heat-based modalities, with reported OS of 88%, 78%, and 67% at 1, 2, and 3 years, respectively (34,35). Although SBRT has not consistently shown superior survival outcomes compared with ablative therapies, limited studies have reported OS rates with CA in the 84–87% range, which appear higher than those reported for RFA, MWA, or SBRT (typically 36–59%). However, these findings should be interpreted cautiously, given the smaller and more selective CA datasets (34).

Pulmonary metastases

As previously mentioned, ablation can also be performed for oligometastatic disease. The most common primary cancers to metastasize to the lung are colorectal (25.8%), head and neck (19.4%), urologic (14.7%), gastrointestinal non-colonic (10.9%), breast (10.5%), melanoma (6.5%), and gynecologic (6.1%) malignancies (38). Heat-based ablation modalities, such as RFA and MWA, have been the most frequently used for these cases. Jiang et al. performed a network meta-analysis focused on ablation outcomes for both primary lung cancers and pulmonary metastases. In the subset of pulmonary metastases, they found that both RFA and MWA were associated with significantly lower local tumor progression rates compared to CA, with no significant difference between RFA and MWA themselves. Despite these differences in local control, major complication rates were similar across modalities. The findings suggest that for pulmonary metastases, heat-based ablations RFA or MWA may offer superior LTC compared to CA, although the analysis was limited by low-quality evidence and heterogeneity among studies (39).

More recently, a 2025 retrospective series of 225 patients (720 lesions) undergoing MWA for colorectal lung metastases reported 1-, 2-, and 3-year local tumor progression-free survival (LTPFS) rates of approximately 91.9%, 85.9%, and 81.5%, respectively, with a median chemotherapy-free interval of 12 months (40). This adds to the growing evidence that MWA can provide durable local control in oligometastatic colorectal pulmonary disease. A separate 2025 retrospective cohort of 82 patients treated with MWA for multiple colorectal lung metastases demonstrated a median OS of 25 months, further supporting the use of thermal ablation in this setting (41).

In addition, a 2025 single-center report of 15 MWA sessions for lung metastases from parathyroid carcinoma showed a statistically significant decline in serum parathyroid hormone (PTH) levels after ablation, accompanied by improvements in corrected calcium, suggesting that percutaneous ablation in hormonally active metastatic disease may offer biochemical as well as locoregional benefit (42).

Taken together, these emerging data support a potential and expanding role for percutaneous ablation in the management of pulmonary metastases, although prospective studies are still needed to better define patient selection and long-term outcomes.

Repeat and salvage ablation

Multiple options exist for managing recurrent lung cancer, including surgery, SBRT, ablation, systemic therapy, or combined approaches. While evidence remains limited, thermal ablation is emerging as a feasible option in this setting (43,44). Kodama et al. reported grade III–IV adverse events in 3 of 55 patients undergoing RFA for post-surgical lung cancer recurrence (45). In a 2018 comparative study by Brooks et al., thermal ablation of recurrent lung tumors resulted in no adverse events, compared with rates of 6.7% and 40% for repeat radiotherapy and surgery, respectively (46). In patients with NSCLC recurrence after SBRT, Fish et al. (10) demonstrated that percutaneous CA achieves 64.9% 2-year local control and 62.3% 2-year OS, outcomes comparable to repeat SBRT, with the added advantage of lung function preservation and an acceptable safety profile.

Safety and complications

Adverse events following lung ablation include pneumothorax, pulmonary hemorrhage, pleural effusion, pneumonia, and bronchopleural fistula (20). Pneumothorax is so frequent that some consider it an expected procedural outcome, analogous to the intentional pneumothorax induced during thoracic surgery. In a meta-analysis of lung tumor ablation, pneumothorax rates were 34.3% for RFA and 33.9% for MWA, with 12.3% and 11.0%, respectively, requiring chest tube placement (6). Pleural effusions occurred in 5.2% of RFA cases and 9.6% of MWA, though severe effusions (grade 3 or 4) were rare at 0.6% and 0.3%, respectively (6). Compared with heat-based ablation, CA may offer a lower side-effect profile. In a network meta-analysis comparing RFA, MWA, and CA, the weighted adverse event rate for CA was 4.6%, compared with 11.6% for RFA and 22.5% for MWA (39).

Comparison with other local therapies

The efficacy of thermal ablation compared with other local therapies is primarily supported by retrospective analyses, as no large, randomized trials currently exist. A meta-analysis of eight studies comparing ablation to surgical resection in stage IA NSCLC found that MWA and surgery demonstrated no significant difference in 1- to 5-year OS or cancer-specific survival. Surgery, however, showed improved disease-free survival at 1 and 2 years, with no significant difference at 3 and 5 years. In contrast, RFA was associated with worse 1- and 2-year OS compared to both MWA and surgery (14).

A separate meta-analysis comparing wedge resection to ablation, also including eight studies, found superior disease-free survival and OS with wedge resection. However, only one of the included studies involved MWA; the rest assessed RFA or unspecified modalities. Notably, hospital length of stay was shorter with ablation, highlighting a potential procedural advantage (47). Based on current evidence, surgical resection remains the standard first-line treatment for early-stage NSCLC.

In medically inoperable patients, both SBRT and ablation are considered curative-intent options (44). Early studies comparing RFA to SBRT demonstrated significantly better local control (1–5 years) and 3- and 5-year OS with SBRT (42). In a more recent analysis comparing MWA, RFA, and SBRT, SBRT again showed superior local control (4% vs. 11% for RFA, 18% for MWA at 1 year). However, MWA achieved the longest disease-free survival and the highest OS at the 2-year mark, though this survival benefit was not significant at later time points (48).

As noted previously, CA remains the least studied modality, but early data suggest it may offer better tissue preservation and preservation of lung function and comparable or improved survival compared to both heat-based ablation and SBRT in select patients (35).

Given the evolving role of ablation in early-stage NSCLC, it is critical for interventional radiologists to actively participate in multidisciplinary tumor boards. While surgery remains the treatment of choice, ablation may be ideal for patients with limited pulmonary reserve or tumors near critical structures (49). For example, lesions adjacent to the esophagus, trachea, or mediastinum may be better managed with ablation due to reduced risk of radiation-induced injury. Similarly, peripheral lesions near the pleura, particularly in patients with compromised lung function, may be more amenable to ablation, avoiding the larger parenchymal loss associated with wedge resection.

Emerging technologies and future directions

There is a growing number of reports supporting the efficacy of CA for lung tumors. In addition to its technical and safety advantages, CA may promote tumor apoptosis in a manner that enhances the abscopal effect, potentially stimulating systemic anti-tumor immunity (50,51). In a study of 161 patients with stage IV NSCLC, those treated with CA in combination with chemotherapy or immunotherapy had significantly improved OS (18 and 17 months, respectively) compared to those treated with chemotherapy or immunotherapy alone (9 and 12 months, respectively) (11,52).

In parallel with conventional percutaneous approaches, emerging platforms such as bronchoscopic and robotic-assisted ablation are under development. Bronchoscopic RFA has already been employed in humans, and animal studies are currently evaluating bronchoscopic MWA. While promising, the clinical utility of these techniques remains in the early stages of investigation (53).

Other local modalities under development for lung tumors include high-intensity focused ultrasound (HIFU) and irreversible electroporation (IRE) (54,55). However, these technologies remain largely experimental, with most data limited to preclinical or animal models.

Lastly, while artificial intelligence (AI) has not yet been applied broadly in lung tumor ablation, its potential is noteworthy. AI has shown early promise in ablation planning for cardiac arrhythmias (56), and similar strategies may soon be translated to pulmonary interventions, offering opportunities for personalized ablation planning, probe placement optimization, and complication risk prediction.

Discussion

This review article provides a comprehensive overview of thermal ablation techniques for the treatment of lung tumors, with a clear comparison of radiofrequency ablation, MWA, and CA in terms of LTC and OS. Its strengths include the inclusion of recent comparative data, a balanced discussion of efficacy and safety, and clinically relevant interpretation of outcomes across modalities. However, the review is limited by the heterogeneity of source studies, particularly with respect to tumor size, patient selection, and procedural protocols, which makes direct comparison challenging. Additionally, long-term survival data for newer modalities like CA remain limited, and some cited studies rely on small cohorts or retrospective designs. Overall, the article is valuable for the clinical context but should be interpreted with caution due to variability in underlying evidence. Future studies should prioritize prospective, standardized, and comparative evaluations of ablation modalities to better define optimal patient selection and long-term outcomes.

Conclusions

Thermal ablation has become an increasingly important tool in the management of both primary and metastatic lung tumors, particularly for patients who are not surgical candidates. Among the available modalities, CA offers unique advantages in preserving lung architecture, minimizing procedural discomfort, and potentially enhancing immune-mediated tumor response. While SBRT currently provides superior local control in early-stage disease, the OS associated with ablation, especially CA, can be comparable in carefully selected patients.

Importantly, ablation may be preferred in clinical scenarios where radiation or surgery pose elevated risks, such as in patients with limited pulmonary reserve or tumors near central structures. As new technologies evolve, including bronchoscopic and robotic-assisted delivery, non-thermal energy modalities, and AI-driven procedural planning, the scope and precision of lung tumor ablation are expected to expand significantly.

Interventional radiologists should play an active role in multidisciplinary tumor boards to help identify patients who may benefit from ablation. Continued research, including prospective and randomized studies, will be essential to further define the optimal role of ablation within the broader landscape of thoracic oncology.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://cco.amegroups.com/article/view/10.21037/cco-25-114/rc

Peer Review File: Available at https://cco.amegroups.com/article/view/10.21037/cco-25-114/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://cco.amegroups.com/article/view/10.21037/cco-25-114/coif). D.C.M. serves as an unpaid editorial board member of Chinese Clinical Oncology from December 2024 to November 2026, and serves on Boston Scientific’s Interventional Oncology Advisory Board. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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