Digital Twin Technology for Image-Guided Thermal Ablation of Pulmonary Nodules: From Computational Proof-of-Concept to Clinical Translation

Image-guided thermal ablation has matured into a recognized local therapy for medically inoperable early-stage non-small cell lung cancer and selected pulmonary metastases, and transbronchial approaches delivered through navigational bronchoscopy are now extending ablation to patients who cannot tolerate pleural puncture. Yet ablation planning remains strikingly empirical: target coverage is estimated from manufacturer-provided geometric charts derived from ex vivo or non-pulmonary tissue, while the two features that most distinguish the lung from other ablated organs, respiratory motion and the low thermal and electrical conductivity of aerated parenchyma, are handled by operator experience rather than by patient-specific modeling. Digital twin (DT) technology, defined here as a patient-specific computational replica coupled to its physical counterpart through bidirectional data flow, offers a framework to close this gap. In this narrative review we (i) summarize the clinical maturity of percutaneous and transbronchial lung ablation that makes planning the rate-limiting step; (ii) propose a three-tier terminological hierarchy (static model, digital shadow, and digital twin) to discipline a literature in which the term is increasingly diluted; (iii) map a four-layer technical stack for a lung ablation DT, spanning four-dimensional anatomical modeling, respiratory-motion compensation, energy–tissue coupling simulation, and intraoperative closed-loop updating, and show that every layer already has validated components in adjacent fields, including a biophysical DT of liver microwave ablation, histology-validated dielectric characterization of human lung carcinoma, and retrospective computational validation of lung microwave ablation models against post-treatment imaging; and (iv) outline a staged validation pathway and a five-item research agenda, arguing that the first integrated, closed-loop DT for pulmonary ablation, percutaneous or transbronchial, remains to be built, and that the specialty which builds it will define the next standard of ablation planning.