Ricerc@Sapienza

In addition to classical metastatic pathways, recently gastric cancer was described having an alternative route
called “endoluminal exfoliation”. Provisional analyses demonstrated, in fact, this kind of shedding is associated
with several clinico-pathological features indicative of aggressive behavior and resulted to be an independent
prognostic factor entailing poor prognosis. Compared with non-sowing counterparts, in fact, patients affected
with exfoliating early and advanced gastric carcinomas met with shorter overall survival, disease free survival,
progression free survival and time to tumor progression. In spite of these interesting results, however, the
clinico-pathological and oncological significance of this unconventional metastatic route is still to be clarified.
Such an investigation is further urged by the increasing widespread employment of minimally invasive treatments
for gastric cancer which include a wide spectrum of intragastric interventions and maneuvers. Indeed,
endoscopic mucosal resection, endoscopic submucosal dissection, endoscopic full-thickness resection, intragastric
laparoscopic surgery and hybrid procedures all take place inside of the stomach. However, iatrogenic
perforations can occur during execution of these treatments leading to spillage of malignant cells from gastric to
the peritoneal cavity or trocar insertion sites. Furthermore, many other gastric conditions and interventions can
collide with endogastric presence of floating cancer cells: spontaneous ulceration or perforation, laparotomy
surgery, gastrointestinal occlusion, diverticula. Viability, migration and intraluminal transportability of the
intragastric floating cancer cells represents another original and intriguing topic. All these considerations led us
to entertain the hypothesis that removing the exfoliated cancer cells from the gastric lumen could save patients
from the dreaded potential risk of spillage. Performing gastric lavage before starting any kind of tumor intervention
could be the most appropriate procedure to adopt with prophylactic intent. Should our speculation
prove to be clinically significant, preoperative gastric lavage should be pointed out as a simple but cogent
method useful for preventing oncological mishaps such as spillage of gastric cancer cells and development of
related recurrences or metastases.