Gastric Neuroendocrine Tumors: Current Evidence and Challenges in Endoscopic Management

Gastric neuroendocrine tumors (G-NETs) represent a heterogeneous group of neoplasms, traditionally classified into three types with distinct pathophysiological backgrounds, biological behavior, and prognosis. Endoscopic treatment plays a central role in the management of type I G-NETs, ranging from endoscopic surveillance to resection with conventional or more advanced techniques. These include endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and, more recently, modified EMR techniques and endoscopic full-thickness resection (EFTR). However, in the absence of high-quality comparative data, the optimal selection among these approaches remains uncertain. Furthermore, incomplete (R1) resection and tumor recurrence represent clinically relevant scenarios frequently encountered in the management of type I G-NETs. However, the clinical significance of R1 resection and the factors associated with recurrence remain incompletely understood, making their subsequent management and surveillance challenging. In type III G-NETs, surgical treatment has traditionally represented the standard approach due to their more aggressive behavior; however, increasing evidence supports the role of endoscopic treatment in carefully selected patients. This review discusses clinically relevant aspects of the endoscopic management of G-NETs, while also highlighting the limitations and gaps in the available evidence and identifying areas for future research. Ultimately, through a critical interpretation of current evidence, this review aims to provide practical guidance for clinical decision-making and contribute to a more evidence-based approach to the management of G-NETs.