What about thermal ablation in NSCLC?
In the ongoing battle against non-small cell lung cancer (NSCLC), lobectomy remains the established standard for early-stage disease. However, for an increasing number of high-risk patients—those with comorbidities, compromised pulmonary function, or advanced age—image-guided thermal ablation (IGTA) emerges as a compelling alternative. This modality, refined over more than two decades, challenges traditional approaches with its precision, cost-effectiveness, and ability to spare lung tissue. At ECIO 2026, we will explore IGTA’s role in NSCLC management, drawing on robust evidence to highlight its potential and limitations.
The value of IGTA is evident, particularly in stage I NSCLC, where up to 30% of patients may be unfit for lobectomy [2]. Introduced in 2001 for pulmonary tumors, IGTA employs percutaneous [5], CT-guided delivery of extreme temperatures: heat via radiofrequency ablation (RFA, up to 100°C) or microwave ablation (MWA, achieving larger zones at higher temperatures), or freezing through cryoablation (below -40°C). This induces cellular necrosis in the tumor and a surrounding margin, with minimal disruption to adjacent healthy parenchyma. Unlike surgical resection, IGTA avoids general anesthesia, enables outpatient procedures in many cases, and preserves pulmonary function—studies consistently report no significant decline in FEV1 or DLCO post-treatment [1].
In high-risk stage I NSCLC, IGTA competes with sublobar resection and stereotactic ablative radiotherapy (SABR). Systematic reviews by the American Association for Thoracic Surgery (AATS) synthesize data from thousands of patients: RFA yields local control rates of 47-90%, with optimal results in tumors under 3 cm (up to 90% control) [1]. MWA extends ablation volumes, reporting 5-year overall survival (OS) of 16-33% in select series, while cryoablation offers advantages in peripheral lesions with reduced hemorrhage risk [1]. Across modalities, pooled 5-year outcomes include OS of 16-68% (e.g., 16% in MWA series, up to 68% in cryoablation cohorts), progression-free survival of 30-50%, and local recurrence-free survival of 70-85% [5]—figures comparable to SABR in retrospective analyses from registries like the National Cancer Database (NCDB) and Surveillance, Epidemiology, and End Results (SEER), where no OS differences appear in propensity-matched cohorts [3, 5].
Critically, however, IGTA remains underutilized, with adoption varying by region—more prevalent in Asia than in North America, where SABR predominates, while in Europe, CIRSE endorses IGTA (RFA, MWA, cryoablation) for lung tumors via practice standards, though SABR prevails in most radiotherapy centers per ESTRO guidelines [3]. This disparity stems from a lack of large randomized controlled trials (RCTs) comparing IGTA directly to SABR or sublobar resection. Retrospective data indicate sublobar surgery may achieve superior primary tumor control (90% vs. 80% for IGTA), but often at the expense of higher morbidity, extended recovery, and lung volume loss [3]. IGTA’s re-treatability stands out: in cases of post-SABR recurrence (10-20%), it offers 70-80% control in oligometastatic or recurrent scenarios, even following prior radiation or surgery [5].
IGTA also holds promise in advanced NSCLC, particularly oligometastatic disease, where integration with systemic therapies like immunotherapy may enhance outcomes. Ablation’s release of tumor antigens could potentiate PD-1 inhibitors, with preliminary evidence of abscopal effects shrinking distant metastases [5]. For patients with interstitial lung disease (ILD), where SABR risks severe pneumonitis, IGTA demonstrates lower complication rates [3].
Challenges include higher local failure in tumors exceeding 3 cm or near central structures, where vascular heat sink reduces efficacy to 50% [1]. Common complications like pneumothorax (20-50%) are typically manageable, with severe events such as hemorrhage or fistula occurring in under 5% [1]. Optimal application requires biopsy-confirmed NSCLC, lesions under 5 cm, and multidisciplinary assessment [4].
Looking ahead, advancements in AI-driven planning, robotic assistance, and hybrid regimens promise greater accuracy. Thermal ablation is not merely an adjunct but a transformative option in NSCLC care, balancing oncologic efficacy with quality of life. Join us at ECIO 2026 to examine the data and consider its integration into practice—innovation in oncology demands such scrutiny.
