Abstract
BACKGROUND/OBJECTIVES: Despite substantial progress in understanding its pathophysiology and risk factors, gastric cancer remains a significant global health burden. Advances in endoscopic technology have improved the potential for early detection, yet variability in clinical practice persists. In this comprehensive narrative review, we summarize the most recent epidemiological trends in gastric pre-neoplastic and neoplastic lesions and critically appraise current evidence on optimizing endoscopic techniques and strategies for the detection of early gastric neoplasia, with an emphasis on emerging innovations. METHODS: The relevant literature on epidemiology, risk factors, pathophysiology, and endoscopic management of GC was selectively reviewed based on the authors' expertise and appraisal of contemporary evidence. RESULTS: Marked global disparities persist in GC incidence, mortality, and stage at diagnosis. Interval GC-including missed lesions and so-called "true" interval cancers-remains a clinically relevant challenge and is frequently identified at advanced stages. These gaps are partly attributable to inconsistent quality in diagnostic esophagogastroduodenoscopy (EGD). High-quality EGD relies on adequate mucosal inspection time, systematic photodocumentation, optimal gastric preparation, and the use of standardized terminology, including mucosal visibility scores. Routine integration of chromoendoscopy and magnification techniques further enhances detection rates. Looking ahead, artificial intelligence holds promise as a transformative adjunct to standardize and augment real-time lesion recognition and quality assurance. CONCLUSIONS: High-quality endoscopic evaluation, coupled with tailored surveillance strategies, enables earlier detection of pre-neoplastic lesions and early gastric cancer, improving clinical outcomes. Future priorities include broadening access to high-quality endoscopy, harmonizing performance standards, and promoting continuous training alongside technological integration.