Comparative study of bronchoscopic and CT-guided percutaneous microwave ablation for inoperable non-small cell lung cancer

Introduction

Lung cancer is one of the most common malignancies in the world, posing a major challenge to global public health (1). Currently, surgical resection remains the gold standard for the treatment of early-stage non-small cell lung cancer (NSCLC) (2). However, there remains an urgent need for non-invasive or minimally invasive treatment options for patients who are not surgical candidates due to comorbid conditions. In recent years, thermal ablation has emerged as a prominent area of research within the field of oncology. Current guidelines from the American College of Chest Physicians recommend thermal ablation as a therapeutic option for medically inoperable patients with stage I NSCLC (3).

Local thermal ablation, such as microwave ablation (MWA) or radiofrequency ablation (RFA), offers several advantages over other local treatment modalities for lung cancer, especially for those patients who cannot tolerate stereotactic body radiation therapy (SBRT). Unlike SBRT, which requires multiple radiation sessions and may cause cumulative toxicity to adjacent structures, thermal ablation delivers immediate cytotoxic effects through coagulative necrosis for rapid lesion control. In contrast, SBRT carries the risk of radiation pneumonitis and affects healthy lung parenchyma, potentially leading to a decline in lung function for lung cancer patients (4). Additionally, thermal ablation is minimally invasive, does not rely on ionizing radiation, and can be completed in a single session, making it a favorable option for elderly patients or those with comorbidities who are unfit for surgery. Compared to pulsed electric field (PEF)—a nonthermal technique still under investigation—thermal ablation is technically mature and less dependent on precise electrical pulse modulation (5,6). Some studies have indicated that patients with NSCLC who underwent SBRT or thermal ablation exhibited comparable outcomes (7,8). Compared to RFA, MWA induces a faster and more substantial temperature increase, with less dependence on thermal conduction (9). Consequently, MWA results in more uniform ablation zones within a shorter time frame and is less prone to the heat sink effect (10). Evidence suggests that MWA is an efficacious method for the treatment of lung tumors (4,11).

As a relatively novel local treatment modality, computed tomography (CT)-guided percutaneous microwave ablation (PTMA) has demonstrated favorable outcomes in patients with medically inoperable or surgery-rejected lung cancer and has garnered increasing global attention due to its minimally invasive nature and immediate cytotoxic effect (12,13). However, procedure-related complications—such as localized pain, pneumothorax, pleural effusion, and tract seeding—remain clinical concerns, particularly in lesions adjacent to the pleura or in patients with underlying lung comorbidities. In parallel, bronchoscopic interventional technologies for lung cancer have progressed rapidly in recent years, offering a promising alternative for accurate diagnosis and therapeutic delivery in early-stage or peripheral lung lesions (14-16). Commonly used bronchoscopic approaches include virtual bronchoscopic navigation (VBN), electromagnetic navigation bronchoscopy (ENB), and radial endobronchial ultrasound (rEBUS), often in combination with ENB for enhanced lesion localization (17,18).

The objective of this study was to evaluate and compare the efficacy and safety of CT-guided PMWA and navigation-guided bronchoscopic transbronchial microwave ablation (BTMA) in the treatment of nonsurgical NSCLC patients, aiming to lay a foundation for future treatment strategies. We present this article in accordance with the STROBE reporting checklist (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-277/rc).

Methods

Patients

The data of 126 patients admitted to the Beijing Chaoyang Hospital, Capital Medical University, from April 2021 to May 2023 were subjected to retrospective analysis. The specific inclusion and exclusion criteria are outlined below: The inclusion criteria were as follows: (I) patients aged 18 years or older; (II) lesions confirmed as primary lung malignancies through pathological biopsy; (III) patients ineligible for surgery due to advanced age, poor cardiopulmonary function, other health conditions, or personal refusal of surgery/SBRT; (IV) lesion distance from critical structures (e.g., heart, major blood vessels) >1 cm; (V) lesion diameter ≤3 cm, with ≤3 lesions in a single lobe; (VI) excluding pregnancy, coagulopathy, severe mental illness, hypoxemia, hemodynamic instability, or pacemaker installation; (VII) informed consent obtained from the patient. Patients were grouped primarily on the basis of imaging features and the availability of the ablation technique. For pulmonary nodules with a positive bronchial sign or those located adjacent to a bronchus, navigation bronchoscopy was employed for ablation. In cases where the lesions did not exhibit these features, CT-guided percutaneous ablation was performed.

This study was registered on the Chinese Clinical Trial Registry (ID: ChiCTR2300076517). The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee for Human Studies of Beijing Chaoyang Hospital, China (No. 2023-KE-432). Written informed consent was obtained from all patients undergoing the procedures.

Procedure

All patients underwent contrast-enhanced chest CT within two weeks before ablation. All procedures were also performed using the Vison Medical MWA system (Vison Medical USA Inc.), operating at a frequency of 2.45 GHz. For the PTMA group, the patient underwent the operation under local anesthesia. We used a percutaneous, water-cooled microwave antenna (Model: MTC-3CA-II6), which was inserted under real-time spiral CT guidance. For the BTMA group, the patient underwent the operation under general anesthesia. We used a specially designed flexible MWA catheter (Model: MTC-3CA-II37), compatible with the working channel of standard therapeutic bronchoscopes (≥2.0 mm). This catheter was delivered to peripheral lung lesions using ENB (Super Dimension V7, Medtronic, Inc., Minneapolis, USA) and guided by intraoperative cone-beam CT (Cios Spin, Siemens, Inc., Erlangen, Germany). Preprocedural CT data were imported into the navigation planning system to reconstruct a virtual bronchial pathway and determine the optimal route to the peripheral pulmonary nodule. Following registration and real-time navigation, a locatable guide (LG) and extended working channel (EWC) were advanced through the bronchoscope (BF-1TQ290, Olympus, Inc., Tokyo, Japan; external diameter 6.0 mm, Working aperture 3.0 mm) to the vicinity of the lesion (17). Positioning was verified by rEBUS and cone-beam CT (CBCT), ensuring accurate alignment with the target. Once the lesion was localized, an MWA antenna was inserted via the EWC. Microwave energy was then delivered at a predetermined power for a specified duration, depending on tumor size and location. To ensure complete ablation, it is recommended that the ablation zone encompass both the target lesion and a 5–10 mm margin of surrounding normal lung tissue (19). Patients were monitored postoperatively for potential complications such as pneumothorax, hemorrhage, or infection.

Characteristics and outcome measures

We collected patients’ baseline information, including demographic data (age, sex, smoking history), comorbidities, and clinical characteristics. Additionally, we recorded lung nodule-specific data, such as the size, location, and density of each nodule as assessed by CT imaging. All scans were independently reviewed by two thoracic radiologists directly involved in the study, with discrepancies resolved through consensus. Lung nodule diameter was measured according to international standards, defined as the average of the maximum long axis (L) and the maximum short axis (S) measured on the axial CT image, i.e., nodule diameter = (L + S)/2. This method is based on the guidelines of the Fleischner Society and the American College of Chest Physicians (20). To facilitate a detailed comparison of the ablative power received by each lung nodule, we applied the equation Energy (J) = Power (W) × Time (S). This allowed for a more precise assessment of the relationship between energy delivery and nodule characteristics during the ablation procedure.

The primary endpoint of this study was: Complete ablation rate at six months after the procedure (CT findings at 4 weeks after ablation were generally used as baseline) (21). A diagnosis of complete ablation was made if any of the following imaging features were observed: (I) Disappearance of the lesion; (II) complete cavitation of the lesion; (III) fibrosis or scar formation in the ablation area; (IV) solid nodule shows reduction, no change, or even enlargement (possible proliferative fibrosis) in size, but with no enhancement on contrast-enhanced CT and/or no metabolic activity on positron emission tomography–computed tomography (PET-CT); (5) atelectasis involving the lesion, with no enhancement on contrast-enhanced CT and/or no metabolic activity on PET/CT within the area of atelectasis (21,22). The secondary endpoints included: (I) local control rate (LCR): defined as the proportion of lesions without radiological evidence of local tumor progression within the ablation zone during the follow-up period. Tumor progression was evaluated according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST), with progression defined as lesion enlargement exceeding 20% from baseline or the reappearance of contrast enhancement within the ablation zone. (II) Progression-free survival (PFS): defined as the time interval from the date of the ablation procedure to the date of first documented disease progression (either local, regional, or distant) or death owing to any cause, whichever occurred first. (III) Technical success rate: defined as the successful completion of the ablation procedure with appropriate placement of the microwave antenna, full coverage of the target lesion, and an ablation zone extending at least 5 mm beyond the tumor margin, as confirmed by intraoperative imaging (23,24). (IV) Procedure-related complication rate: defined as the incidence of adverse events following MWA, including but not limited to pneumothorax, hemoptysis, pleural effusion, pulmonary infection, air embolism, and post-ablation syndrome.

Statistical analysis

SPSS 26.0 software was used for data analysis. Descriptive statistics were used to summarize patient demographics, lesion characteristics, and treatment-related parameters. Categorical variables were presented as counts and percentages, while continuous variables were expressed as mean ± standard deviation (SD) or median with interquartile range (IQR), depending on the distribution. Differences between groups were assessed using the Mann-Whitney U test for continuous variables. Categorical variables were compared using the chi-square test or Fisher’s exact test, as appropriate. The Kaplan-Meier method was used to analyze PFS. All data were checked for missingness and censored appropriately in time-to-event analyses. A P value of ≤0.05 was considered significant.

Results

Baseline characteristics

A total of 126 patients were enrolled in the study between April 2021 and May 2023. The baseline characteristics of the patients are presented in Table 1. A total of 131 lung nodules were ablated, with five patients undergoing ablation of multiple nodules. Demographic and clinical characteristics, including age, sex, smoking history, Charlson Comorbidity Index (CCI), tumor size, and histological type, were similar between the two groups. No significant differences were observed in the baseline characteristics, indicating that the groups were well-matched at the time of enrollment. The mean diameter of the nodules was 13.28±5.44 mm in the BTMA group and 11.28±6.10 mm in the PTMA group. Pulmonary lesions in the BTMA group were predominantly located in the middle third of the lung, with an average pleural distance of 26.43±18.20 mm, whereas those in the PTMA group were mainly peripheral, with an average distance of 13.79±17.47 mm. The difference between the two groups was statistically significant (P<0.001).

Procedural and imaging characteristics

In terms of the energy of MWA, the median and interquartile range of ablation energy in the PTMA and BTMA group were 12,000.00 (7,650.00–19,200.00) and 36,000.00 (23,550.00–36,000.00), respectively. There was a significant difference between the two groups (P<0.001).

In addition, we compared the lesion diameters and their reductions at different post-ablation time points between the two groups (Table 2). At 1 day (D_1d), 1 month (D_1m), and 3 months (D_3m) post-ablation, the mean target zone diameters were significantly greater in the BTMA group than in the PTMA group (D_1d: 30.9±11.2 vs. 26.39±8.84 mm, P=0.015; D_1m: 22.88±11.70 vs. 18.42±9.81 mm, P=0.037; D_3m: 16.98±8.71 vs. 12.45±6.32 mm, P=0.005). However, there were no significant differences between the two groups in the degree of diameter reduction at each time point. The mean reductions were comparable in terms of d1 (D_1d–D_1m), d2 (D_1d–D_3m), and d3 (D_1m–D_3m), with P values of 0.37, 0.23, and 0.66, respectively. The temporal evolution of post-ablation CT features is illustrated in Figure 1. Consolidation and ground glass opacity (GGO) were the predominant findings immediately after ablation, with a gradual decline over time. In contrast, fibrotic bands and scar formation increased progressively, becoming the most common findings at 12 months. Pneumatoceles might develop after ablation and could evolve into cavitation over time; however, the proportion of cavitary lesions gradually decreased during the follow-up period.

Figure 1 Temporal trends of CT imaging features following microwave ablation. The figure shows the relative incidence of consolidation, GGO, cavitation, pneumatocele, fibrotic bands, atelectasis, and scar formation at immediate, 1-month, 3-month, and 12-month follow-up. CT, computed tomography; GGO, ground-glass opacity.

The primary outcomes

At 6 months post-treatment, the complete ablation rate was assessed using CT findings at 4 weeks as the baseline for comparison. For the PTMA group, the complete ablation rate was 95.5%, while the BTMA group showed a rate of 96.7%. The difference in complete ablation rates between the two groups was not statistically significant (P>0.99). In addition, subgroup analyses stratified by age (<65 and ≥65 years), nodule size (≤10, 11–20, and 21–30 mm), and nodule density (pure GGO, mixed GGO, and solid) were conducted. The corresponding results are illustrated in Table 3.

The secondary outcomes

LCR and PFS

During the follow-up period, the BTMA and PTMA groups demonstrated comparable therapeutic efficacy. At 12 months, the LCRs were 95.0% in the BTMA group and 95.5% in the PTMA group, while the PFS rates were 91.7% and 90.9%, respectively. The Kaplan-Meier curves for PFS are represented in Figure 2. No statistically significant difference was observed between the two groups (log-rank P=0.62). The subgroup analysis based on nodule size showed significant differences in PFS in both the PTMA (P=0.03) and BTMA (P=0.03) groups. Patients with larger nodules tended to have lower PFS. More detailed information is presented in Table 3 and Figure 3.

Figure 2 Kaplan-Meier curves for PFS within 12 months following microwave ablation in the two groups. The figure illustrates the Kaplan-Meier curves for PFS within 12 months following microwave ablation in the PTMA and BTMA groups. The red curve represents the PTMA group, while the blue curve corresponds to the BTMA group. There was no statistically significant difference in PFS between the two groups during the follow-up period. The shaded areas indicate the 95% confidence intervals for each group. BTMA, bronchoscopy-guided microwave ablation; PFS, progression-free survival; PTMA, percutaneous microwave ablation.

Figure 3 Kaplan-Meier curves of progression-free survival stratified by nodule size in the PTMA group (A) and BTMA group (B). No significant difference in PFS was found among nodule size subgroups in the BTMA group and PTMA group. Shaded areas represent 95% confidence intervals. BTMA, bronchoscopy-guided microwave ablation; PFS, progression-free survival; PTMA, percutaneous microwave ablation.

Technical success rate

Both PTMA and BTMA showed high technical success rates, with no significant difference between the two groups (P>0.68). Successful ablation was achieved in 64 of 66 patients (97.0%) in the PTMA group and 56 of 60 patients (93.3%) in the BTMA group. Six patients who experienced initial ablation failure due to positioning errors underwent re-ablation within 6 months, all of which were successful.

Procedure-related complication rate

Chest pain occurred in 44 patients (66.7%) in the PTMA group and 6 patients (10.0%) in the BTMA group, with a significant difference between groups (P<0.001). Pneumothorax requiring thoracentesis was also more frequent in the PTMA group (18.8% vs. 3.3%; P=0.006). There were no significant differences in other complications. For detailed information, please refer to Figure 4.

Figure 4 Complication incidence following different treatment methods. This bar chart illustrated the incidence of various complications following two treatment methods, PTMA (N=66) and BTMA (N=60). The orange bars represent PTMA, while the blue bars represent BTMA. The x-axis indicates the number of occurrences, and the y-axis lists the types of complications, including post-ablation syndrome, infection, pleural effusion, hemoptysis, thoracic drainage, pneumothorax, and pain. BTMA, bronchoscopy-guided microwave ablation; PTMA, percutaneous microwave ablation.

Discussion

In this study, we compared the clinical outcomes and safety profiles of two different approaches for MWA in the treatment of primary lung tumors: CT-guided percutaneous MWA and bronchoscopic navigation-guided MWA. Our findings demonstrated that the bronchoscopic approach was associated with a significantly lower incidence of procedure-related complications while achieving comparable outcomes in terms of LCR, complete ablation rate, technical success rate, and PFS.

Among the complications, pneumothorax and pain were significantly more frequent in the CT-guided group, likely due to pleural and parenchymal violation during antenna insertion. The bronchoscopic approach, by contrast, avoids pleural disruption and may be more suitable for patients with compromised pulmonary reserve or central lesions. These findings are consistent with previous studies highlighting navigational bronchoscopy as a less invasive and safer alternative for accessing intrapulmonary tumors (11,25,26). Hemoptysis, pleural effusion, and infection were also observed as common complications; however, no significant differences were found between the two groups. Importantly, no cases of massive or clinically significant hemoptysis were reported in our cohort. This complication is rare, likely due to the heat-sink effect, induced by blood flow, which facilitates a good hemostatic effect. Due to the absorption of necrotic tissue and the release of inflammatory mediators, approximately one-third of patients may develop post-ablation syndrome (27). The typical symptoms include low-grade fever, fatigue, general malaise, nausea, and vomiting, which usually persist for 3 to 5 days, although in some cases they may last up to 2 weeks. In our study, there was no significant difference in the incidence of post-ablation syndrome between the two groups. Other rare but potentially serious complications, such as air embolism, nerve injury, bronchopleural fistula, and pulmonary embolism, have been reported in the literature (28); however, none of these adverse events occurred in our cohort.

Of note, we observed no statistically significant differences in oncologic efficacy between the two approaches. Both techniques achieved satisfactory LCR and PFS, suggesting that bronchoscopic ablation can be a clinically viable option. Chan et al. (24) performed ENB-guided MWA on 30 pulmonary nodules in 25 patients, with an average diameter of 15.1 mm. The treatment of pulmonary nodules was successful 100% in the cases, with a low incidence of complications. After a median follow-up of 12 months, there was no evidence of progression in all nodules, demonstrating the efficacy and safety of the treatment. Huang et al. (29) reported 51 patients with lung adenocarcinoma who received 52 MWA treatments, with an average follow-up of 27.2 months. The 3-year PFS, cancer-specific survival, and overall survival were 98%, 100%, and 96%, respectively. The efficacy of the procedure was comparable with that of surgical intervention. Our research revealed that the PFS of lung cancer with a diameter greater than 2 cm was lower than that of tumors with a diameter less than 2 cm, which was consistent with the results of previous studies (21,30). In addition, six patients in our study underwent secondary ablation after failure of the initial procedure. In these cases, technical failure in lesion localization occurred due to factors such as small lesion size, poor lesion visualization from adjacent pulmonary structures (e.g., emphysema or atelectasis), patient movement during the procedure, or limitations in safe access routes due to critical anatomical structures. These challenges may impede accurate antenna placement or complete lesion coverage during the initial procedure. These patients subsequently underwent a second ablation procedure within the same treatment modality group to ensure adequate treatment.

To date, no specific guidelines pertaining to the particulars of MWA in the context of the treatment of lung malignant tumors have been established. Furthermore, the potential effects of varying ablation power and duration are currently being investigated. The most commonly utilized ablation power ranges from 20 to 100 W, with the ablation time controlled within a 10-minute window. Sebek et al. (31) conducted MWA on a porcine lung model with the assistance of a virtual bronchoscope. The ablation power was maintained at 24–32 W, with each ablation lasting approximately 5–10 minutes. In a prospective single-arm study by Xie et al. (32), the recommended power for ablation cycle was 50–80 W and lasted 3–10 minutes. Wolf et al. (25) performed CT-guided percutaneous MWA on 50 patients, and the ablation power was controlled at 50–60 W for 5–10 minutes.

In our study, the median ablation energy in the BTMA group was significantly higher than that in the PTMA group. Several factors may contribute to this difference.

First, in BTMA, the microwave antenna was delivered through the bronchial lumen. During energy transmission, a considerable amount of heat is dissipated along the bronchial wall and airway, resulting in reduced effective energy reaching the target tissue (33). To compensate for this loss, operators often increased the energy output or prolonged the ablation time. Second, despite the use of electromagnetic navigation and CBCT guidance, minor localization errors may occur, particularly for peripheral or distal bronchial lesions, leading operators to deliver redundant energy to ensure sufficient margins. Third, unlike PTMA, where the antenna is directly inserted into the center of the tumor, the distal end of the BTMA catheter may not be in tight contact with the lesion. Instead, it interacts with the target tissue indirectly through the bronchial wall, leading to a smaller tissue contact area and thus requiring higher energy to achieve comparable ablation volumes. In addition, CBCT, which is used intraoperatively in the BTMA group, has lower spatial resolution than conventional spiral CT, particularly in evaluating subtle changes in lung parenchyma (34,35). This limitation may lead to the underestimation of the ablation zone, further prompting bronchoscopists to adopt a more conservative approach by increasing energy delivery.

Besides efficacy and safety, this study also provides valuable insights into the dynamic radiological evolution of the ablation zone. Based on serial CT follow-ups at 1, 3, and 12 months, we observed characteristic changes in ablation morphology. Typically, at day 1 post-ablation, the treated zone appears as a dense consolidation, often with central cavitation due to coagulative necrosis and tissue vaporization. Over time, this consolidation tends to gradually shrink, with fibrotic remodeling leading to linear or band-like scarring after 6 to 12 months. It is noteworthy that our study revealed the occurrence of cavitation or pneumatocele in a subset of patients following ablation. This may be attributable to the elevated temperatures, excessive ablation energy, or the patient’s preexisting emphysema. However, almost all instances of cavitation were resolved within one to three months following surgery (36). This transient radiological change has also been reported in prior literature, with Okuma et al. documenting a 14% incidence rate of post-RFA cavitation at approximately 1.5 months (37). Interestingly, some studies suggest that the formation of a cavitation may correlate with favorable local tumor control, possibly due to a higher percentage of complete necrosis of the target tissue (38-40). To illustrate these imaging changes, Figure 5 presents a representative case of a 66-year-old man with a history of smoking, hypertension, and diabetes, who underwent ENB-guided biopsy and MWA for a pulmonary nodule (15 mm × 13 mm) in the posterior basal segment of the right lower lobe. CT at 1-day post-ablation revealed enlargement of the lesion with dense consolidation and cavitation. At 6 months, the lesion had markedly regressed, leaving only minimal fibrotic changes. A clear understanding of the radiological evolution following thermal ablation is critical to avoiding misinterpreting expected post-treatment changes—such as fibrosis, cavitation, or volume fluctuation—as residual tumor or recurrence. Improved familiarity with typical imaging patterns can reduce diagnostic uncertainty, minimize unnecessary interventions, and optimize post-ablation monitoring strategies.

Figure 5 Chest CT images of a 66-year-old male with lung adenocarcinoma following electromagnetic navigation bronchoscopy-guided microwave ablation. This figure presents a series of chest CT images from a 66-year-old male patient with a history of smoking, hypertension, and diabetes, who underwent ablation guided by electromagnetic navigation bronchoscopy. (A) Pre-ablation CT showing the original pulmonary nodule (highlighted in red). (B) Post-ablation CT immediately after the procedure, showing the area of ablation (highlighted in red). (C) Follow-up CT at 3 months post-operation, demonstrating initial changes in the nodule (highlighted in red). (D) Follow-up CT at 6 months post-operation, showing significant reduction in the nodule size with minimal residual fibrous tissue (highlighted in red). CT, computed tomography.

Nonetheless, this study has several limitations. Its retrospective design, relatively small sample size, and short follow-up time may limit the generalizability of the results. In parallel, our findings support the potential of BTMA as a minimally invasive treatment option for selected patients with early-stage NSCLC who are ineligible for surgery or radiotherapy. For lesions with bronchial passage, ablation treatment via navigational bronchoscopy may be a more optimal ablation treatment option. To establish its role in clinical practice, future prospective studies should focus on developing standardized procedural protocols, aligning intraoperative imaging criteria, and ensuring systematic long-term follow-up to comprehensively evaluate therapeutic efficacy, recurrence rates, and late-onset complications. These efforts will be critical for guiding evidence-based implementation and refining patient selection for BTMA.

Conclusions

Bronchoscopic navigation-guided MWA and CT-guided PMWA both achieved comparable efficacy in treating lung tumors. However, BTMA was associated with fewer complications, especially pneumothorax and pain. Serial CT follow-ups revealed predictable post-ablation imaging patterns, emphasizing the importance of recognizing normal evolution to avoid misdiagnosis. PTMA presents a safe, minimally invasive alternative for patients at high surgical risk and warrants further validation in larger prospective studies.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-277/rc

Data Sharing Statement: Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-277/dss

Peer Review File: Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-277/prf

Funding: This work was supported by Beijing Research Ward Demonstration Construction Project (No. BCRW202110) and Capital’s Funds for Health Improvement and Research (No. 2024-2-1063).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-277/coif). The authors have 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. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee for Human Studies of Beijing Chao-yang Hospital, China (No. 2023-KE-432) and written informed consent was obtained from all patients undergoing the procedures.

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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