Management of gastric neoplasia

Despite a decreasing incidence, gastric cancer remains the sixth most common cancer and the third most common cause of cancer-related death worldwide, underscoring the importance of early diagnosis to enable curative treatment. Most gastric cancers are preceded by pre-cancerous conditions, including chronic atrophic gastritis and gastric intestinal metaplasia, with Helicobacter pylori infection and autoimmunity being the strongest pathogenetic factors. Increasing quality of endoscopy systems along with widespread availability of image-enhanced and magnification endoscopy have significantly improved our chances of early detection and have created opportunities to predict the pathological features of premalignant conditions and early malignant lesions. Over the past two decades, there has been a paradigm shift in the management of early gastric cancer, with expanding indications for organ-sparing treatments, particularly endoscopic submucosal dissection. En bloc resection allows precise staging and risk stratification based on depth of invasion, grade of differentiation and presence of lymph-vascular invasion, thereby allowing tailored treatment. Looking ahead, future advancements are likely to include opportunities for broader screening through blood-based technologies, improved detection with artificial intelligence and more refined risk stratification using molecular biomarkers.