The patient’s story began long before the ablation. A former smoker with a 45 pack-year history, he was already fighting urothelial carcinoma of the bladder, staged as pT2 with lymph node involvement and suspected pulmonary metastases. He was on maintenance immunotherapy with avelumab, and immunohistochemical testing showed PD-L1 expression between 25 and 30 percent. During routine surveillance in 2023, a high-resolution chest CT with 1-millimeter slices and multiplanar reconstructions revealed that a subpleural nodule in his left upper lobe had grown from 11 to 16 millimeters. A CT-guided biopsy confirmed a primary squamous cell carcinoma — p40 positive, TTF-1 positive only in rare cells, GATA3 negative — a profile consistent with a primary lung squamous cancer rather than a bladder metastasis.

His lung function, however, told a sobering story. Pulmonary function tests revealed severe obstructive ventilatory impairment: an FEV1 of 1.32 liters, just 48 percent of predicted, an FEV1/FVC ratio of 54 percent, and a diffusion capacity for carbon monoxide at only 42 percent of predicted. That marked reduction in diffusion capacity, despite relatively limited radiologic emphysema, signaled underlying interstitial lung disease on top of severe emphysema. A multidisciplinary tumor board concluded that lobectomy — the surgical gold standard — posed unacceptable perioperative risk given his limited pulmonary reserve. Percutaneous radiofrequency ablation was chosen as the next step, an option the National Comprehensive Cancer Network guidelines recognize for patients who cannot tolerate surgery.

Before the procedure, a pulmonary consultation flagged the high risk from his interstitial lung disease and recommended corticosteroid therapy and bronchoalveolar lavage. The lavage came back positive for Haemophilus influenzae, which was treated appropriately. The ablation itself then proceeded without immediate complications: a Cambridge 3-centimeter, 17-gauge needle delivered a 12-minute treatment at 98 watts, totaling 71 kilojoules. The immediate post-procedural CT showed exactly what interventional radiologists expect — a circumferential ground-glass halo surrounding the ablation zone — and, crucially, no evidence of pneumothorax.

Four weeks later, the complication struck. The patient arrived at the emergency department with acute severe dyspnea. Chest CT revealed a left-sided pneumothorax with associated subcutaneous emphysema, air that had escaped the lung and tracked into the tissues of his chest wall. A chest tube was placed in the fifth intercostal space and connected to continuous suction. Yet despite 12 days of drainage, persistent bubbling indicated an ongoing air leak with incomplete lung re-expansion. Conservative management had failed, and chemical pleurodesis — the usual fallback — would have been ineffective anyway, since pleurodesis requires the lung to sit flush against the chest wall, something impossible with a substantial ongoing leak and incomplete re-expansion.

Surgical exploration followed. Under general anesthesia with double-lumen intubation and a lung-protective ventilation strategy, the team performed uniportal video-assisted thoracic surgery, or UVATS, entering the chest through a single incision. What they found explained everything: a 1.5-centimeter necrotic subpleural parenchymal defect at the ablation site, with pneumatic testing confirming active air leakage. The surrounding emphysematous lung was markedly friable — tissue so fragile that stapling it would have risked creating new air leaks at the staple lines. No central bronchopleural fistula involving segmental bronchi was identified, meaning the leak came from the necrotic surface itself rather than a fistulized airway.

Here the case becomes technically remarkable. Wedge resection was deemed unsafe given the patient’s borderline pulmonary reserve and the risk of additional staple-line leaks. Instead, the surgeons applied Hemopatch, a flexible, resorbable collagen pad derived from bovine dermis and coated with a reactive layer of N-hydroxysuccinimide functionalized polyethylene glycol. Upon contact with moist tissue, the NHS-PEG component forms covalent bonds with tissue proteins, creating a rapid and strong mechanical seal, while the collagen matrix promotes platelet adhesion and supports hemostasis. Over this, they applied Tisseel, a two-component fibrin sealant made of human-derived fibrinogen and thrombin that replicates the final steps of coagulation, forming a stable fibrin clot. Tisseel was applied both centrally and along the lesion margins, reinforcing the seal and penetrating tissue irregularities that the patch alone could not reach. Multiple parietal pleural biopsies were taken for histologic and microbiological analysis, and a 20 French chest tube connected to a digital drainage system was placed apically. Low-pressure re-expansion confirmed the absence of any residual air leak.

The recovery was swift. Postoperatively, no residual air leak was observed. A one-way valve was attached on postoperative day 5, and the patient was discharged on day 10. Histologic analysis of the biopsies revealed fibrotic tissue and fibrinous exudate with chronic inflammatory infiltrates — the fingerprint of slow post-ablation necrosis rather than infection. Follow-up imaging at two and four months showed no recurrence of pneumothorax, resolution of the subcutaneous emphysema, and signs of localized post-ablation consolidation with a small air bubble but no active leak. The sealants had achieved durable, long-term resolution of a complication that drainage alone could not touch.

The broader context makes this case resonate. Lung cancer screening programs have increased the detection of early-stage non-small cell lung cancer, and squamous cell carcinoma remains a significant subtype. Surgical resection is still the gold standard for operable disease, but comorbidities such as chronic obstructive pulmonary disease, interstitial lung disease, or poor general condition often contraindicate surgery. In these high-risk patients, percutaneous RFA has emerged as a valid option for localized disease in the absence of nodal involvement. RFA works through thermal coagulation necrosis, exploiting the low impedance of air-filled lung tissue to localize damage within the tumor — effectively delivering the outcomes of an R0 resection in suitable candidates. But pneumothorax remains its most frequent complication, with incidence rates between 10 and 60 percent. Other short-term complications include pleural effusion and pulmonary hemorrhage, while rarer reported events encompass pneumonia, bronchopleural fistula, pleuritis, lung abscess, gas embolism, rib or vertebral injury, pericardial effusion, cardiac arrhythmias, and myocardial infarction.

What sets this report apart is the timing and the mechanism. Delayed complications of pulmonary RFA are sparsely documented, and bronchopleural fistula has been the only delayed complication consistently reported in the literature. No previous case has described a delayed air leak arising from progressive post-ablation necrosis without fistulization. The authors argue that surgical intervention — including parenchymal resection — is reserved for cases with prolonged air leak, underlying infection, or failure of conservative strategies, and that minimally invasive approaches allow targeted treatment with reduced postoperative morbidity and mortality. When resection is unfeasible because of lesion proximity to the hilum, necrotic tissue, or the risk of functional loss, biologic sealants could offer an effective alternative. This combination, although well documented in thoracic surgery generally, had never been described in the context of RFA-related complications. The case underscores the need for long-term vigilance after ablation, the value of a multidisciplinary approach, the utility of UVATS in managing non-resolving pneumothorax, and the technical relevance of low-pressure lung re-expansion. In appropriately selected patients, this conservative-surgical hybrid approach may provide definitive treatment while preserving lung function — a message that could reshape how clinicians think about the weeks and months that follow a lung ablation.

Subject of Research: Interventional Radiology and Thoracic Surgery

Article Title: Surgical management of delayed air leakage following radiofrequency ablation for non-small cell lung cancer: a case report

Article References: Surgical management of delayed air leakage following radiofrequency ablation for non-small cell lung cancer: a case report. (n.d.). https://doi.org/10.3389/fradi.2026.1815270

Image Credits: AI Generated

DOI: 10.3389/fradi.2026.1815270

Keywords: radiofrequency ablation, non-small cell lung cancer, persistent air leak, biologic sealants, UVATS, delayed pneumothorax, interventional radiology, Surgical, management, delayed, leakage, following