Image-Guided Ablative Therapies for Lung Tumors

While the gold standard for early stage lung cancers is still surgical resection, many patients have comorbidities or suboptimal lung function making surgery unfavorable. At the same time, more and more small lung nodules are being incidentally discovered on computer tomography (CT), leading to the discovery of pre-malignant or very early stage lung cancers without regional spread, which could probably be eradicated without anatomical surgical resection. Various ablative energies and technologies are available on the market, including radiofrequency ablation, microwave ablation, cryoablation, and less commonly laser ablation and irreversible electroporation. For each technology, the mechanism of action, advantages, limitations, potential complications and evidence-based outcomes will be reviewed. Traditionally, these ablative therapies were done under CT guidance with percutaneous insertion of ablative probes. Recently, bronchoscopic ablation under ultrasound, CT, or electromagnetic navigation bronchoscopy guidance is gaining popularity due to improved navigation precision, reduced pleural-based complications, and providing a true “wound-less” option.


Introduction
With the increasing availability of computer tomography (CT) scans and enlarging body of evidence for low-dose CT screening in high risk populations, a rising number of lung nodules are discovered incidentally. Many of them are small, sub-solid, and harbor pre-malignant or early stage cancers. Local therapies for these lesions are gaining evidence support, especially in patients with high surgical risks or decline surgery. Sublobar resection has been shown to confer similar 5-year survival rates, especially in older patients, tumor smaller than 2 cm, and pure bronchoalveolar carcinoma [1][2][3]. Stereotactic body radiation therapy (SBRT) is targeted toward patients with stage I or II non-small cell lung carcinoma (NSCLC) without lymph node involvement and who are medically inoperable. SBRT has a local control rate of more than 80% in multiple retrospective series [4], and disease-free survival of 26% and overall survival of 40% at 4 years in a multicentre phase II study [5]. However, sublobar resection still carries surgical risks while SBRT has up to 22.3% risk of radiation pneumonitis and pneumonia. Since the early 2000s, percutaneous ablation of lung tumors has been attempted [6] following reports of efficacy of local ablation in liver cancers. The subsequent decade saw the blossom

Procedure and planning
Pre-procedure workup includes CT imaging ideally within 4 weeks of the planned ablation date. Patients were fasted overnight before ablation to reduce risk of sedation-induced nausea and aspiration. Anti-coagulation or anti-platelet medications were stopped as per regional guidelines for invasive procedures. Implantable cardiac devices like pacemakers or defibrillators are susceptible to interference from certain ablation modalities, and should be interrogated and programed by cardiac electrophysiologist to automatic pacing modes, or by placing a magnet over the device, while defibrillation should be turned off during ablation. Grounding pads should be placed to guide the flow of current away from the cardiac device and Image-Guided Ablative Therapies for Lung Tumors DOI: http://dx.doi.org /10.5772/intechopen.94216 electrodes should be inserted at least 5 cm away from pacemaker or defibrillator leads. External pacing and defibrillator system should be readily available in case of emergency.
Most ablation strategies are performed percutaneously, and nearly all are done under CT guidance. The great majority of ablation are performed with conscious sedation, while general anesthesia is reserved for pediatric patients or patients who cannot tolerate sedation alone, although some authors have reported higher feasibility rates and lower peri-procedural pain with general anesthesia [13]. For certain ablation energies, a reference electrode or grounding pad is necessary, which is attached to patient's skin usually on the opposite chest wall or thigh. Initial scout CT images are acquired; the skin entry site is determined and cross-marked on the skin by laser lights from the CT gantry. Following sterile preparation and draping, local anesthesia is injected along the tract from skin to the level of pleura. A spinal needle is advanced according to the planned trajectory with CT and/or fluoroscopy guidance, which is then exchanged to the ablation electrode after confirmation of correct placement.
The aim of all ablation modalities is to create a zone of tissue necrosis that encompasses both the tumor and a margin of normal parenchyma surrounding it. The choice of electrode length, active tip length and the number of electrodes is determined by the size and location of tumor. The actual ablation zone size may differ from the predicted size. Factors include the heat-sink effect [14], which refers to the fact that medium to large blood vessels or airways carry heat away leading to asymmetrical or truncated ablation zones. Depending on the energy used, the lung's conductivity, impedance and density also play a role in affecting the eventual ablation zone volume. In general, microwave is able to produce a larger ablation zone than radiofrequency due to its mechanism of energy deposition [15], with explanation detailed later in the chapter. After the initial ablation, a CT evaluation of ablation effect should be performed. In case of inadequate ablation volume, re-ablation with several overlapping ablation zones, or exchange to larger and more powerful electrodes can be performed.
After ablation and removal of electrode, CT images are acquired to evaluate technical success and rule out any complications, for example pneumothorax and bleeding. Patients are observed for 2-4 hours and a repeat chest x-ray confirms the absence of pneumothorax. Most patients are discharged the same day if no complications arise. Median length of stay was 1 day in a nation-wide review [16]. Subsequent follow up required interval CT scans for evaluation of treatment response, usually every 3 months although no international guideline exists [17]. Typical early CT appearances following heat-based thermal ablation (eg. RFA, MWA) include ground glass opacities (GGO) or cavities, with or without soft tissue components. The GGO is typically concentric with three layers, the central consolidation represents ablated tumor tissue, the middle layer of faint GGO represents necrotic surrounding parenchyma, and an outer rim of denser GGO contains congested lung tissue and hemorrhage than may retain viability [17]. Cavitation, which is considered a positive response, is most likely to appear in the intermediate phase (1 week to 2 months after ablation). At 3 to 6 months post-ablation, the ablated area continues to involute and shrink down to a linear or nodular scar, or even a thinwalled cavity. Enlarging ablation zone beyond 6 months is highly suggestive for tumor recurrence. Central enhancement >10 mm or > 15HU suggests progression of incompletely ablated disease on contrast CT scans [18], while increased metabolic   activity or new uptake inside the ablation zone beyond 2 months post-ablation are worrisome of recurrence on PET/CT scans [19]. Patients with local recurrence can undergo repeated ablation to improve local control. Figures 1-3 show the typical appearance of successfully ablated lung tumors over serial CT imagings. CT-guided ablation of centrally located metastasis can be combined with surgical resection of other more peripheral lung metastases as part of lung-preserving strategy, as illustrated in

Ablation energies
Ablation techniques can be divided into thermal or non-thermal ablations (e.g. irreversible electroporation). Among thermal ablations, heat-based techniques include radiofrequency ablation, microwave ablation and laser ablation, while coldbased technique includes cryoablation. Table 1 shows the comparison of thermal ablation modalities in the lung.

Radiofrequency ablation (RFA)
Radiofrequency ablation is the most widely used ablative modality in the lung, and utilizes heat as a form of thermal ablation. Radiofrequency refers to a section in the electromagnetic spectrum with frequency ranging between 20 kHz to 30 MHz, but most clinically available devices function in the 375-500KHz range. A grounding pad or reference electrode is required in RFA, while the active electrode placed inside the tumor is coupled to an RF generator. The RF generator establishes a voltage between the active electrode and reference electrode, producing electric field lines that oscillate with alternating current. At the area closest to the applicator, electrons collide with adjacent molecules under the influence of oscillating electric field, inducing frictional heating [20]. Immediate cell death occurs at temperatures greater than 60°C. RF electrodes have an internal thermocouple that measures the temperature at the tip. Charring and desiccation at the electrode increases impedance and reduces heat conduction, thus most commercially available electrodes are coupled with infusion pumps that pump cold saline to internally cool the electrode tip. Treatments usually range between 4 and 12 minutes, and RFA electrodes may be single-tip applicators or cluster electrodes.
Multiple RFA systems are commercially available (Boston Scientific, Watertown, MA, USA; StarBurst (RITA) Medical Systems, Mountain View, CA, USA; Cool-Tip, Covidien, Boulder, CO, USA). The first two use a deployable radiofrequency array electrode with 4-16 small wires tines through a 14-to 17-gauge needle. The third system consists of a single or triple cluster (3 electrodes spaced 5 mm apart) electrode perfused with saline, and a switching controller allow for simultaneous placement of up to three separate single electrodes to create a greater volume of thermocoagulation in a single application.

Efficacy of radiofrequency ablation
The local control and survival rates of RFA have been examined in a handful of non-randomized single-institutional series and a few multicenter trials. The RAPTURE study published in 2008 is a prospective, intention-to-treat, multicenter trial involving seven centres in Europe, USA and Australia [21]. It included 106 patients with 183 biopsy-proven lung tumors, although there was a mixture of NSCLC and lung metastases. Technical success rate was 99%, and a confirmed complete response lasting at least 1 year was achieved in 88% of patients. For patients with NSCLC, overall survival was 70% at 1 year and 48% at 2 years, cancer-specific survival was 92% at 1 year and 73% at 2 years. Selecting those with stage 1 NSCLC, the 2-year overall survival was 75% and cancer-specific survival was 92%. More recently, another multicenter trial, the ALLIANCE Trial, was published in 2015 [9]. The overall survival was 86.3% at one year and 69.8% at two years, while local recurrence-free rate was 68.9% at one year and 59.8% at two years.
Regarding long term efficacy, a retrospective study revealed that for stage I NSCLC, the overall survival rate was 36% and 27% at 3 and 5 years respectively [10]. In another prospective intention-to-treat study, the complete response rate was 59.3% at a mean follow-up of 47 months, with a mean local recurrence interval of 25.9 months [22]. Median overall survival and cancer-specific survival were 33.4 and 41.4 months respectively, while cancer-specific actuarial survival was 59% at 3 years and 40% at 5 years [22].
Tumor diameter was found to be a negative prognostic factor. The difference between survival curves associated with large (>3 cm) and small (<=3 cm) lung tumors was significant (p = 0.002, 10], and there was a trend toward better efficacy for tumors smaller than 2 cm in diameter (p = 0.066, 23]. Tumor size less than 2 cm was associated with a statistically significant improved survival of 83% at two years in the ALLIANCE Trial [9]. In another study, complete necrosis was attained in all tumors less than 3 cm but only in 23% of larger tumors, and the mean survival of patients with complete necrosis was significantly better than that with partial necrosis [11]. An ablation area of at least 4 times larger than initial tumor was reported to be predictive of complete ablation treatment [23]. To date, there are no properly powered prospective trials comparing one RFA system with another or comparing RFA with other treatment modalities. There has been a propensity-matched analysis comparing RFA and surgery for stage 1 NSCLC, and the mean survival duration of RFA group and surgery group was 33.2 +/− 7.9 and 45.4 +/− 7.2 months respectively, although the difference is not statistically significant [24]. A large propensity-matched retrospective study comparing thermal ablation (mostly RFA) with SBRT using the National Cancer Database reported no significant difference in overall survival at a mean follow up of 52.4 months, however unplanned hospital readmission rates were high in the thermal ablation group [25]. In a systemic analysis and pooled review, the local control rate was significantly lower in the RFA group compared to SBRT, although the overall survival remained similar [26].

Microwave ablation (MWA)
Microwave ablation for lung tumors has been gaining increasing momentum since the mid-2000s. Microwave occupies a much higher frequency range in the Lung Cancer -Modern Multidisciplinary Management electromagnetic spectrum between 300 MHz to 300 GHz. Compared to radiofrequency, microwave energy is able to create a much larger zone of active heating due to broader deposition of energy. Clinically available microwave applicators generally operate in the 900-245 MHz range [27]. MWA directly heats tissue to lethal temperatures greater than 150°C through dielectric hysteresis, which is a process in which the polar water molecules realign with the oscillating electric field generating kinetic energy, which is then transferred to neighboring tissues [28]. Being completely independent from electrical conductance, microwave energy deposition is less susceptible to tissue impedance, and is able to produce faster, larger and more predictable ablation zones than RFA [15]. The aerated lung has a relatively high impedance among all solid organs, thus making MWA a better modality than RFA in lungs [15,29]. Heat-sink effect is also smaller with microwave [28].
There are 7 microwave systems commercially available in the United States and Europe, using either 915 MHz or 2450 MHz generators [30]. The antennae are generally straight, ranging from 14 to 17 gauge, with varying active tips of 0.6-4.0 cm in length. Five out of seven systems require perfusion of antenna shaft with room-temperature fluid or carbon dioxide to reduce conductive heating of the non-active portion of the antennae, which protects the skin and other tissues from thermal damage.

Efficacy of microwave ablation
The majority of evidence supporting the efficacy of MWA comes from retrospective data. The earlier studies reported an actuarial survival of 65% at 1 year, 55% at 2 years and 45% at 3 years, while cancer-specific survival was 83%, 73% and 61% at 1, 2 and 3 years respectively [31]. A more recent retrospective study reported cancer-specific survival of 69%, 54% and 49% at 1, 2 and 3 years respectively, and the mean survival was 27.8 months [32]. Local control rate was 84.4% at a mean follow-up of 446 days in another retrospective series [33]. A larger retrospective review of 108 patients reported that the median time to tumor recurrence was 62 months, and recurrence rates were 22%, 36% and 44% at 1, 2 and 3 years respectively [34]. It should be noted that the majority of the studies include both primary and secondary lung tumors, and results for NSCLC may not be separately reported. Longer term results were reported in a study involving large NSCLC (mean tumor size of 5.0+/− 1.8 cm). Owing to the larger tumor size, only 44.6% of cases achieved complete tumor ablation after first ablation, and 18.5% required a re-do MWA session. The 3-and 5-year cancer-specific survival rates were 42.1% and 30.0% respectively, and the median cancer-specific survival was 25 months [35].
Similar to RFA, tumor size is associated with poorer prognosis. For every millimeter increase in tumor maximal diameter, the odds of not attaining technical success increased by 7% [34]. Tumor size >4 cm is a significant predictor for local tumor progression and poorer survival [35]. Recurrence rate was 17% for tumors smaller than 3 cm, and increased to 31% for those greater than 3 cm [34]. A risk-factor analysis demonstrated that local tumor progression was significantly correlated with tumor diameter of more than 15.5 mm, irregular shape of index tumor, pleural contact and low energy deployed per unit volume of index tumor [36]. On the other hand, cavitation was associated with reduced cancer-specific mortality [31].
Again, there are no prospective studies comparing one MWA system with another, or with other modalities. There was a propensity-score matched analysis comparing MWA with lobectomy for stage I NSCLC, which reported no significant difference in overall survival and disease free survival ( for lobectomy group) [37]. The complication rate in MWA group was significantly lower than lobectomy group (p = 0.008). However, the power of this study is undermined by the relatively poor results in lobectomy group when compared to international standard, probably due to poor patient premorbid. In a best evidence topic review, the best available evidence for MWA (7 studies) was compared to that for SBRT (5 studies) [38]. The 3-year survival was 29.2-84.7% for MWA and 42.7-63.5% for SBRT, while the median survival was 35-60 months for MWA and 32.6-48 months for SBRT. The authors concluded that MWA appears comparable to SBRT in terms of local control and survival rates. In the randomized controlled LUMIRA trial, 52 patients with stage IV lung tumors were recruited, and there was no significant difference in survival between the MWA group and RFA group, but MWA was found to produce less intraprocedural pain and a more significant reduction in tumor mass [39].

Percutaneous Cryoablation
Cryoablation makes use of the Joule-Thomson effect by distributing pressured argon gas to an area of lower pressure and reaching ultracold temperatures when the gas expands [40]. As low as −140°C can be achieved, although living tissue destruction already happens at −40°C. Cryogenic destruction occurs via a number of mechanisms, including protein denaturation, cell rupture due to osmotic shifts, and tissue ischemia from microvascular thrombosis [41]. Meanwhile, the term "cryosurgery" includes cryoablation performed through endobronchial, direct intrathoracic or percutaneous routes.
Traditionally, each cryoablation consists of a dual freeze cycle, involving a 10-minute freeze, followed by 8-minute helium thaw and another 10-minute freeze. Early animal models suggest that air leaks and bleeding could be reduced with this protocol [42]. Current commercially available cryoablation devices (for example Cryocare CS® system, Endocare, Irvine, CA, USA) use a faster cycle of 3-minute freeze, 3-minute thaw, 7-minute freeze, 7-minute thaw and a final 5-minute freeze. These systems allow placement of 1-10 individual 1.5-2.4 mm diameter cryoprobes, and one freeze-thaw-freeze cycle at a single probe position usually suffice. The faster cycle produces interstitial fluid in adjacent lung tissue and improves margin control. Radiologically, a visible "ice ball" and surrounding edematous changes can be seen on CT and serve as an estimation of ablation zone. The true volume of tissue necrosis has been shown to be 3-7 mm from the ice-ball edge [43], and should be taken into consideration when determining cytotoxic ice margin clearance.
Compared with heat-based thermoablation like RFA and MWA, cryoablation has the advantage of larger ablation volumes, availability of multiple applicators, a highly visible ablation zone (a clearly defined ice ball as opposed to concentric ground glass opacities in RFA or microwave), and less pain due to analgesic effect of freezing [44]. Another benefit is its safety near vasculature or bronchi due to the ability to preserve collagenous tissue and cellular architecture in frozen tissue [45]. Disadvantages of cryoablation include a longer procedural time (25 minutes per freeze-thaw-freeze cycle compared to roughly 5 to 10 minutes per ablation in MWA) and a higher incidence of pneumothorax up to 62% [46]. The latter can be tackled with fibrin glue tract coagulation or radiofrequency thermocoagulation of needle tract provided by one of the cryoablation systems.

Efficacy of Cryoablation
A retrospective review of 25 stage I NSCLC treated with cryoablation reported 3-year overall survival of 88% and mean overall survival of 62+/−4 months [47].

Lung Cancer -Modern Multidisciplinary Management
Another study involving 27 cryoablated stage I NSCLC demonstrated 3-year survival of 77%, 3-year cancer-specific survival of 90.2% and cancer-free survival of 45.6% [48]. In a study comprising of cryoablation of both primary and secondary lung tumors, the 1-, 2-and 3-year local progression free rates were reported to be 80.4%, 69.0% and 67.7% respectively [49]. In a long-term analysis of 47 stage I NSCLC treated with cryoablation, the 5-year cancer-specific survival rate was 56.6+/−16.5% and 5-year progression free survival rate was 87.9+/−9% [50]. There were two randomized controlled trials, the ECLIPSE trial [51] and SOLSTICE trial [52], evaluating cryoablation of metastatic lung tumors, which report favorable safety and efficacy, but are out of the scope of this chapter.
Cryoablation has been performed for stage IV lung cancer for palliation of symptoms. In a comparative study between cryoablation and palliative treatment alone, the overall survival of the cryoablation group was significantly longer, with median survival of 14 months compared to 7 months [53]. The same group has performed cryosurgery in various stages of NSCLC yielding an overall survival of 64%, 45% and 32% at 1, 2 and 3 years respectively [54].
Few studies have compared cryoablation with other treatment modalities. In 64 patients with stage I NSCLC deemed medically unfit for lobectomy, 25 were treated with sublobar resection, 12 with RFA and 27 with cryoablation. The 3-year survival rate was similar for the three groups (87.1% for sublobar resection, 87.5% for RFA and 77% for cryoablation) [48]. In a comparative study for stage IIIB or IV NSCLC treated with cryoablation or MWA, the overall survival and progression-free survival were similar for tumors ≤3 cm in diameter, but were poorer in tumors greater than 3 cm which are treated with cryoablation [44].

Percutaneous laser ablation
Laser ablation is a thermal technique where light energy is converted into heat by interaction with sources such as an Nd: YAG laser. Typically, energy is transmitted through a flexible fiberoptic cable which is percutaneously inserted into the lung through an outer sheath. Cooling of the fiberoptic cable enables greater energy deposition and a 50 percent increase in size of thermocoagulation [55], as the size of ablation zone is limited by tissue carbonization near the applicator. To date, there have been limited reports on the efficacy of laser ablation in humans [56]. A long term analysis of laser ablation for lung metastases reported 1-, 3-and 5-year survival of 81%, 44% and 27% respectively [57], with a relatively high rate of pneumothorax (38%). No data is available for primary lung cancers.

Irreversible electroporation (IRE)
Electroporation is a phenomenon in which cell membrane permeability to ions and macromolecules is increased by exposure to high voltage electric pulses. It can be reversible or irreversible, with the latter leading to cell death from loss of homeostasis and osmotic effects. Since IRE is a non-thermal ablation modality, its theoretical advantage includes overcoming the heat-sink effect [58] and preservation of structural integrity of nearby bronchovascular structures [59]. Although there have been reports on its efficacy in animal models [60] and in other organs such as the liver [61], there were few reports on its use in human lungs [62]. In fact, in the multicenter phase II ALICE trial for treatment of primary and secondary lung malignancies, IRE failed to meet the expected efficacy and the trial was terminated prematurely after inclusion of 23 patients, in which 61% showed progressive disease [63]. The disappointing results may be explained by high differences in electric Image-Guided Ablative Therapies for Lung Tumors DOI: http://dx.doi.org /10.5772/intechopen.94216 conductivity between normal lung parenchyma and tumor tissue. Of note, needle tract seeding happened in 13% of cases.

Safety and complications of percutaneous ablation
Percutaneous ablation of lung tumors is generally considered safe. A list of potential complications is presented in Table 2. In a nationwide analysis of 3344 patients who underwent percutaneous lung ablation in the United States [16], in-hospital mortality was 1.3%, and patients with more comorbidities (Charlson comorbidity index score ≥ 4) was associated with significantly higher mortality. The most common complication was pneumothorax (38.4%), followed by pneumonia (5.7%) and effusion (4.0%). In a Japanese review of 1000 RFA sessions [64], there was a 0.4% procedure-related mortality, of which three died of interstitial pneumonia and another died of hemothorax. Major complication rate was 9.8%, consisting of 2.3% aseptic pleuritis, 1.9% pneumonia, 1.6% lung abscess (Figure 5), 1.6% pneumothorax requiring pleural sclerosis, 0.4% bronchopleural fistula and 0.3% brachial nerve injury. Previous radiotherapy and age were significant risk factors for pneumonia, as were emphysema for lung abscess, and platelet count and tumor size for bleeding [64].
Pneumothorax occurs as a result of pleural puncture by the ablation catheter leading to air leak. Hence, unlike standard lung biopsy technique, in which the shortest path to tumor is preferred, some operators advocated a longer distance between pleura puncture site and tumor is more desirable for ablation. An indirect approach that leaves an unablated tract of at least 2 cm of normal lung is preferable [29], because  Table 2.
Complications following thermal ablation in the lung.    unablated pleura contracts less and heals quicker. Emphysema is the most significant risk factor for pneumothorax in multiple studies [65,66]. Other risk factors include male gender, no previous lung surgery, high number of tumors ablated, advanced age, and traversal of major fissure by electrode [67]. The rate of pneumothorax ranges from 3.5-54%, but only 6-29% required chest tube placement [68] (Figure 6). Delayed pneumothorax could occur in up to 10% of cases [69,70]. Around 0.4-0.6% of all patients develop bronchopleural fistula [64,71] leading to intractable pneumothorax not resolving with chest drainage (Figure 7). Treatment strategies include repeated chemical pleurodesis, placement of endobronchial valves (Figure 8), and bronchoscopic embolization of relevant fistulae [68]. Aseptic pleuritis and pleural effusion is postulated to be due to ablation zone reaching pleura leading of pleural inflammation, and is associated with higher   pleural temperatures [72]. Repeated punctures and previous systemic chemotherapy were significant risk factors [64]. Aseptic pleuritis gives rise to pleuritic pain, but most resolve spontaneously. Only a minority of pleural effusion required drainage (Figure 9).
The incidence of hemoptysis after percutaneous RFA is 3-9% [68], while the incidence of all forms of hemorrhage is approximately double that rate. Risk factors for intraparenchymal hemorrhage include basal and middle lung zone lesions, needle track traversing lung parenchyma by more than 2.5 cm, electrode traversing pulmonary vessels and the use of multi-tined electrodes [73]. Although most hemorrhages are self-limiting, rarely ablation injury to intercostal artery may occur leading to massive bleeding [68].

Bronchoscopic ablation techniques
Most of the thermal ablative techniques in literature involved percutaneous placement of electrodes. Since 2010, a Japanese group pioneered a bronchoscopyguided cooled RFA technique for lung tumors in humans [74,75], followed by a Chinese group using electromagnetic navigation bronchoscopy (ENB) guidance [76]. Compared to percutaneous approach, a major advantage of bronchoscopic ablation is lack of pleural puncture, and hence fewer pleural-based complications. The Japanese group reported no pneumothorax, bronchopleural fistula nor pleural effusion in 28 cases of bronchoscopic RFA [75], while the rate of pneumothorax for percutaneous ablation ranges from 3.5-54% as mentioned above. Bronchoscopic ablation also eliminates the risk of needle tract seeding. Another edge of bronchoscopic ablation is its ability to reach certain regions of lung which are otherwise difficult or dangerous for percutaneous access, for instance areas near mediastinal pleura, diaphragm, lung apex, or areas shielded by scapula. With evidence of safety and technical success of bronchoscopic ablation in animal models [77], and the above-mentioned advantages in mind, the author's institute is one of the first to perform ENB-guided microwave ablation on patients in the hybrid operating room (Figure 10). Navigation precision has been much improved following the advent of ENB with the help of navigation systems like SuperDimension™ (Covidien, Plymouth, MN, USA) (Figures 11 and 12), supplemented by position confirmation by fluoroscopy and cone beam CT. The microwave catheter (Emprint™ Ablation Catheter with Thermosphere™ technology, Covidien, Plymouth, MN, USA) is inserted within the lung tumor via bronchoscopy and ablated for up to 10 minutes per burn (Figure 13). Since early  2019, we have performed 45 cases with 100% technical success rate. Similar to percutaneous approach, the median length of stay was 1 day only. Only 2 patients (4.4%) developed pneumothorax requiring chest drainage. Post-ablation reaction and fever occurred in 8.9%, minor hemoptysis or hemorrhage in 4.4%, and pleural effusion in 2.2%. As of the time of writing, there was no progressive disease at a mean follow up of 290 days. We believe that bronchoscopic ablation represents the future for lung cancer ablation as it offers a truly wound-less option with likely fewer complications.

Conclusions
Image-guided ablative therapy is an important armamentarium in the treatment of lung cancers, either for early stage lung cancers in patients who are medically inoperable or refuse surgery, or for palliation of late stage lung cancers. Radiofrequency ablation is the most studied modality with a large body of evidence supporting its safety and efficacy, with comparable outcomes to sublobar resections and stereotactic radiation therapy in select patients. Nonetheless, microwave ablation is quickly catching up in popularity due to its superior properties over RFA. Traditionally, lung ablation was performed percutaneously, but the latest development of bronchoscopic ablation techniques are promising and may drive the future of lung cancer ablation research.

Conflict of interest
Dr. Joyce WY Chan and Dr. Rainbow WH Lau declare no conflict of interest. Professor Calvin SH Ng is a consultant for Johnson and Johnson; Medtronic, USA.  © 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.