Solitary colorectal liver metastasis: overview of treatment strategies and role of prognostic factors.

The following is an overview of the treatment strategies and the prognostic factors to consider in the therapeutic choice of patients characterized by solitary colorectal liver metastasis. Liver resection is the only potential curative option; nevertheless, only 25% of the patients are considered to be eligible for surgery. To expand the potentially resectable pool of patients, surgeons developed multidisciplinary techniques like portal vein embolization, two-stage hepatectomy or associating liver partition and portal vein ligation for staged hepatectomy. Moreover, mini-invasive surgery is gaining support, since it offers lower post-operative complication rates and shorter hospital stay with no differences in long-term outcomes. In case of unresectable disease, various techniques of local ablation have been developed. Radiofrequency ablation is the most commonly used form of thermal ablation: it is widely used for unresectable patients and is trying to find its role in patients with small resectable metastasis. The identification of prognostic factors is crucial in the choice of the treatment strategy. Previous works that focused on patients with solitary colorectal liver metastasis obtained trustable negative predictive factors such as presence of lymph-node metastasis in the primary tumour, synchronous metastasis, R status, right-sided primary colon tumor, and additional presence of extrahepatic tumour lesion. Even the time factor could turn into a predictor of tumour biology as well as further clinical course, and could be helpful to discern patients with worse prognosis.

Strengths and limitations of the Crohn's disease activity index, revealed by an objective gut lavage test of gastrointestinal protein loss.

BACKGROUND: Several factors contribute to overall illness in patients with inflammatory bowel disease. The Crohn's disease activity index (CDAI), correlates closely with symptoms and is widely used to assess efficacy in clinical trials; previous work indicated that a gut lavage test for protein-losing enteropathy (PLE) may measure the same symptomatic, acute inflammatory component of overall inflammatory bowel disease illness. METHODS: Results of the protein-losing enteropathy test have been compared with the CDAI in 42 routinely presenting inflammatory bowel disease patients, and in 26 patients with ileostomies, eight children and five psychologically disturbed individuals with inflammatory bowel disease. RESULTS: For general adult patients with Crohn's disease or ulcerative colitis, concentrations of proteins in gut lavage fluid, particularly IgG, correlated well with CDAI. However, high CDAIs (> 150) were obtained in patients with fibrous small bowel strictures, in psychologically disturbed patients and also in five of seven patients in whom a provisional diagnosis of inflammatory bowel disease was subsequently shown to be wrong. In all these cases, normal values in the protein-losing enteropathy test reinforced the clinical judgement of a low probability of acute inflammatory activity of the inflammatory bowel disease. In the children, results of the protein-losing enteropathy test were positive in all cases; this was consistent with the clinical diagnosis, but CDAI values ranged from -66 to 275. In ileostomy patients, concentrations of IgG in gut lavage fluid discriminated well between groups judged, globally, to have either acute inflammatory activity or inactive disease, but there was no significant association with CDAI. CONCLUSIONS: These data confirm that, in most inflammatory bowel disease patients, the CDAI measures a true biological phenomenon which also causes gastrointestinal protein loss. However there are a number of situations where the CDAI in inappropriate or unreliable; for these, tests based on whole gut lavage, including the protein-losing enteropathy test, offer an alternative method to measure the efficacy of pharmacological and other anti-inflammatory therapies.