Delarbete I

Tidigare studier har visat att tumörstorlek kan begränsa behandlingseffekten vid RFA. Målsättningen var att undersöka vilka faktorer som påverkar be- handlingseffekten vid behandling av små njurtumörer med RFA. En retro- spektiv genomgång utfördes av 52 njurtumörer vilka hade RF-abladerats från 2007 till 2012 på Akademiska Sjukhuset. Samtliga DT-undersökningar före, under och efter behandling granskades inklusive alla kontrollundersökningar. På dessa bedömdes tumörkarakteristika (lokalisation, storlek) samt RF-elek- trodplacering. Från journalen inhämtades uppgifter rörande patient (kön och ålder) och tumör (histopatologisk diagnos). Resultaten visade att en optimal elektrodplacering ökade sannolikheten att uppnå en fullständig ablation efter en behandlingsomgång. Tumörer med en central lokalisation i njuren var svå- rare att fullständigt behandla med endast en ablationsomgång.

9.2 Delarbete II

Allt fler retrospektiva studier har visat jämförbara onkologiska resultat mellan RFA och kirurgisk resektion vid behandling av små njurtumörer. Men vid val av behandlingsmetod måste även hänsyn tas till komplikationsriskerna, pati- ent morbiditeten och kostnaderna. Målet var att jämföra RFA och laparosko- pisk njurresektion (LPN) avseende behandlingseffekt, behandlings- och vård- tid samt komplikationer. Retrospektivt utvärderades 49 LPN- och 84 RFA- behandlade patienter med endast en njurtumör (≤5 cm). Genomgången inne- bar journal- och DT granskning av samtliga pre-operativa undersökningar samt postoperativa kontroller. Resultaten visade att båda behandlingsme-

toderna uppnådde jämförbara behandlingseffekter. RFA innebar fler behand- lingsomgångar, men trots detta var den totala behandlingstiden och vårdtiden betydligt kortare och komplikationsfrekvensen var lägre för dessa jämfört med de LPN-behandlade patienterna.

9.3 Delarbete III

Både RFA och LPN har som mål att vara nefronsparande vid behandling. Men tidigare studier, som utvärderar njurfunktion utifrån blodprover (kreatinin och eGFR), har redovisat motstridiga resultat, utan att utvärdera hur det kvarva- rande njurparenkymet påverkas av behandling. På en kontrastmedelsförstärkt DT kan både kvantitet och kvalitet av njurfunktionen utvärderas genom be- räkning av ”split renal function” (SRF). Målet var att jämföra njurfunktions- påverkan vid RFA och LPN behandling genom beräkning av SRF och utvär- dering av rutinblodprover. Retrospektivt jämfördes 60 RFA och 31 LPN pati- enter behandlade för en tumör vardera. SRF beräknades före och efter behand- ling och njurfunktionsvärden (kreatinin och eGFR) samlades in. Resultaten visade att i båda grupperna minskade SRF i den drabbade njuren, men denna minskning var mer påtaglig i LPN-gruppen. Det fanns ingen skillnad i föränd- ringen av njurfuktionsvärden mellan grupperna.

9.4 Delarbete IV

Mikrovågsablation (MWA) har introducerats med flera fördelar, bl.a. möjlig- gör tekniken kortare ablationstider och en mer förutsägbar ablationszon jäm- fört med RFA. Behandlingen ses fortfarande som experimentell då det finns få långtidsuppföljningar som utvärderar metoden. På Akademiska sjukhuset har MWA använts för behandling av njurtumörer sedan 2014. Målet var att retrospektivt utvärdera behandlingseffekten och komplikationer vid kurativ syftande MWA-behandling av små njurtumörer. Totalt inkluderades 105 bi- opsiverifierade njurtumörer behandlade från april 2014 till augusti 2017 med en medianuppföljningstid på 2 år. Retrospektivt utvärderades samtliga DT- undersökningar (före, under och efter behandling) och från journalen inhäm- tades patient- och tumörinformation samt eventuella behandlingskomplikat- ioner. Resultaten visade goda behandlingseffekter, jämförbara med tidigare ablations-studier samt metaanalyser och komplikationsfrekvensen var låg.

9.5 Konklusion

Perkutan DT-vägledd ablation är en effektiv metod vid behandling av små njurtumörer. Metoden är säker, komplikationsfrekvensen är låg och påverkan

på njurfunktionen är mycket liten. Genom ökad kunskap kring behandlings- metodens fördelar och begränsningar kan vi förbättra urvalet av de patienter som kommer att gynnas av behandling.

10. Acknowledgements

This thesis is the result of all the dedication, teaching, help, patience, multiple emails, phone calls, meetings, conferences, courses, late-night-working-ses- sions, helpful reminders, tips, keep-on-going-you-can-do-it-cheering and end- less support from people who made me get through this process with a smile at the end. I would like to thank all the awesome people, who still keep on doing amazing things, and are truly endless resources of inspiration.

Anders Magnusson, my fantastic “Super Professor” and main supervisor. I will always be grateful for your trust in me, letting me research from different locations and for always asking for my opinion. Thank you for making me feel included in your research group, as a college at work and with your family members. And above all, thank you for making research fun.

Maria Lönnemark, my co-supervisor. Thank you for introducing me to the field of Radiology, for teaching me structure early in my carrier, for your feed- back and support and for giving me opportunities to teach others.

Håkan Ahlström, my co-supervisor. Thank you for your valuable input. To the rest of my co-authors, Pär Dahlman, Einar Brekkan, Michael Häggman, Sam Ladjevardi, Thomas Nilsson, Sarah Båtelsson, and Elina Onkamo. Your contributions made this thesis possible.

Thank you to the rest of our uro-radiology research group. Thank you Malin Helenius, Monica Segelsjö, Pär Dahlman and Klara Sahlén, for your valuable comments and input. Thanks to the students Elinor Wajngot and Carl-Johan Karlsson who chose us as colleagues for their projects.

Lisa Wernroth, my life-saver in statistics. I would be totally lost without your support. Thank you for your explanations, answers and patience.

Håkan Pettersson, solving all my computer issues in a calmly manner. Thank you for making me know that my work is always in good hands.

To my amazing fellow radiology residents at Akademiska Sjukhuset. Thank you for your cheerful messages, pep talks and encouragement. Thank you for

wanting to celebrate this work with me and letting our group know we have each other’s backs. “Vi är bästa ST-gänget!”

To my colleagues at the Department of Radiology at Akademiska Sjukhuset. Thank you for everything you have taught me, keep on teaching, and for the inspiration I receive from you daily.

To the Head of the Radiology Resident program, Allina Dimopoulou Creusen, and the Head of the Radiology Department, Adel Shalabi. Thank you for help- ing me balance my clinical training with research opportunities.

“AT-ledningen” at Akademiska Sjukhuset. Thank you for believing in me and giving me the opportunity to continue my work through a “forskar-AT block”. Thanks to my AT-colleagues, especially my “forskar-AT”-colleagues, who continue to encourage each other. And to my dear friend and colleague Hanna Andersson who has followed me during this process since medical school. Special thanks to my proofreaders, Stephan Foy, Sue Pajuluoma, Christina Lundberg and my father. To Mats Magnusson for plotting graphs and helping with statistics. To the Uppsala University administrative staff at the Radiology Department, especially Christl Richter Frohm, Elin Eriksson and Siv Anders- son for organizing my research process. To the secretaries at the Urology de- partment for helping me gather patient-lists and to nurse Pernilla Helgesson for getting me in contact with patients.

To my relatives and friends. Thank you for cheering on me always and re- minding me to look back on my accomplishments once in a while. Thank you to everybody who keeps in touch from different parts of the world.

The biggest hugs and kisses to my family. “Mami y Papi”, thank you for your unconditional support, phone calls, annual Australia-Sweden trips, love and care. Thank you for our FaceTime rehearsal sessions before every presenta- tion, for your live cheering from the other side of the world in a different time zone, and for letting me become the person I am. Thank you for being my best role models in life. This work is for you.

To my siblings Rafael, Valeria and Sebastian, for reminding me what is im- portant in life, for always making me laugh and keeping me down to earth. And to my favorite person in the world, my husband Renzo. Thank you for making my dreams come true.

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