At a population level, the European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter and Microbiota Study Group (EHMSG), and the European Society of Pathology (ESP) suggest endoscopic screening for gastric cancer (and precancerous conditions) in high-risk regions (age-standardized rate [ASR] > 20 per 100 000 person-years) every 2 to 3 years or, if cost-effectiveness has been proven, in intermediate risk regions (ASR 10-20 per 100 000 person-years) every 5 years, but not in low-risk regions (ASR < 10).ESGE/EHMSG/ESP recommend that irrespective of country of origin, individual gastric risk assessment and stratification of precancerous conditions is recommended for first-time gastroscopy. ESGE/EHMSG/ESP suggest that gastric cancer screening or surveillance in asymptomatic individuals over 80 should be discontinued or not started, and that patients' comorbidities should be considered when treatment of superficial lesions is planned.ESGE/EHMSG/ESP recommend that a high quality endoscopy including the use of virtual chromoendoscopy (VCE), after proper training, is performed for screening, diagnosis, and staging of precancerous conditions (atrophy and intestinal metaplasia) and lesions (dysplasia or cancer), as well as after endoscopic therapy. VCE should be used to guide the sampling site for biopsies in the case of suspected neoplastic lesions as well as to guide biopsies for diagnosis and staging of gastric precancerous conditions, with random biopsies to be taken in the absence of endoscopically suspected changes. When there is a suspected early gastric neoplastic lesion, it should be properly described (location, size, Paris classification, vascular and mucosal pattern), photodocumented, and two targeted biopsies taken.ESGE/EHMSG/ESP do not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection unless there are signs of deep submucosal invasion or if the lesion is not considered suitable for endoscopic resection.ESGE/EHMSG/ESP recommend endoscopic submucosal dissection (ESD) for differentiated gastric lesions clinically staged as dysplastic (low grade and high grade) or as intramucosal carcinoma (of any size if not ulcerated or ≤ 30 mm if ulcerated), with EMR being an alternative for Paris 0-IIa lesions of size ≤ 10 mm with low likelihood of malignancy.ESGE/EHMSG/ESP suggest that a decision about ESD can be considered for malignant lesions clinically staged as having minimal submucosal invasion if differentiated and ≤ 30 mm; or for malignant lesions clinically staged as intramucosal, undifferentiated and ≤ 20 mm; and in both cases with no ulcerative findings.ESGE/EHMSG/ESP recommends patient management based on the following histological risk after endoscopic resection: Curative/very low-risk resection (lymph node metastasis [LNM] risk < 0.5 %-1 %): en bloc R0 resection; dysplastic/pT1a, differentiated lesion, no lymphovascular invasion, independent of size if no ulceration and ≤ 30 mm if ulcerated. No further staging procedure or treatment is recommended.Curative/low-risk resection (LNM risk < 3 %): en bloc R0 resection; lesion with no lymphovascular invasion and: a) pT1b, invasion ≤ 500 μm, differentiated, size ≤ 30 mm; or b) pT1a, undifferentiated, size ≤ 20 mm and no ulceration. Staging should be completed, and further treatment is generally not necessary, but a multidisciplinary discussion is required. Local-risk resection (very low risk of LNM but increased risk of local persistence/recurrence): Piecemeal resection or tumor-positive horizontal margin of a lesion otherwise meeting curative/very low-risk criteria (or meeting low-risk criteria provided that there is no submucosal invasive tumor at the resection margin in the case of piecemeal resection or tumor-positive horizontal margin for pT1b lesions [invasion ≤ 500 μm; well-differentiated; size ≤ 30 mm, and VM0]). Endoscopic surveillance/re-treatment is recommended rather than other additional treatment. High-risk resection (noncurative): Any lesion with any of the following: (a) a positive vertical margin (if carcinoma) or lymphovascular invasion or deep submucosal invasion (> 500 μm from the muscularis mucosae); (b) poorly differentiated lesions if ulceration or size > 20 mm; (c) pT1b differentiated lesions with submucosal invasion ≤ 500 μm with size > 30 mm; or (d) intramucosal ulcerative lesion with size > 30 mm. Complete staging and strong consideration for additional treatments (surgery) in multidisciplinary discussion.ESGE/EHMSG/ESP suggest the use of validated endoscopic classifications of atrophy (e. g. Kimura-Takemoto) or intestinal metaplasia (e. g. endoscopic grading of gastric intestinal metaplasia [EGGIM]) to endoscopically stage precancerous conditions and stratify the risk for gastric cancer.ESGE/EHMSG/ESP recommend that biopsies should be taken from at least two topographic sites (2 biopsies from the antrum/incisura and 2 from the corpus, guided by VCE) in two separate, clearly labeled vials. Additional biopsy from the incisura is optional.ESGE/EHMSG/ESP recommend that patients with extensive endoscopic changes (Kimura C3 + or EGGIM 5 +) or advanced histological stages of atrophic gastritis (severe atrophic changes or intestinal metaplasia, or changes in both antrum and corpus, operative link on gastritis assessment/operative link on gastric intestinal metaplasia [OLGA/OLGIM] III/IV) should be followed up with high quality endoscopy every 3 years, irrespective of the individual's country of origin.ESGE/EHMSG/ESP recommend that no surveillance is proposed for patients with mild to moderate atrophy or intestinal metaplasia restricted to the antrum, in the absence of endoscopic signs of extensive lesions or other risk factors (family history, incomplete intestinal metaplasia, persistent H. pylori infection). This group constitutes most individuals found in clinical practice.ESGE/EHMSG/ESP recommend H. pylori eradication for patients with precancerous conditions and after endoscopic or surgical therapy.ESGE/EHMSG/ESP recommend that patients should be advised to stop smoking and low-dose daily aspirin use may be considered for the prevention of gastric cancer in selected individuals with high risk for cardiovascular events.

2nd Department of Internal Medicine Gastroenterology and Geriatrics University Hospital Olomouc Faculty of Medicine and Dentistry Palacky University Olomouc Olomouc Czech Republic

Agia Olga General Hospital of Nea Ionia Konstantopouleio Athens Greece

Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Spain

Department of Biomedical Sciences Humanitas University Pieve Emanuele Milan Italy

Department of Cellular Pathology Royal Free London NHS Foundation Trust London United Kingdom

Department of Gastroenterology and Digestive Endoscopy Masaryk Memorial Cancer Institute Brno Czech Republic

Department of Gastroenterology and Hepatology Erasmus University Medical Center Rotterdam The Netherlands

Department of Gastroenterology and Hepatology UZ Leuven Leuven Belgium

Department of Gastroenterology Faculty of Medicine Academy of Silesia Katowice Poland

Department of Gastroenterology Pêro da Covilhã Hospital Covilhã Portugal

Department of Hepato Gastroenterology and Digestive Oncology Institut des Maladies de l'Appareil Digestif Centre Hospitalier Universitaire de Nantes Nantes France

Department of Medical Sciences Faculty of Health Sciences University of Beira Interior Covilhã Portugal

Department of Medical Surgical Sciences and Translational Medicine Sant'Andrea Hospital Sapienza University of Rome Italy

Department of Medicine 2 University Hospital LMU Munich Germany

Department of Surgery and Physiology Faculty of Medicine University of Porto Portugal

Department of Surgery University Hospital Brno Faculty of Medicine Masaryk University Brno Czech Republic

Department of Translational Research in Gastrointestinal Diseases KU Leuven Leuven Belgium

Endoscopy Unit Gastroenterology Department Hospital Universitari Germans Trias i Pujol Badalona Spain

Endoscopy Unit Teknon Medical Center Barcelona Spain

Endoterapia H T Centrum Medyczne Tychy Poland

Facultat de Medicina i Ciències de la Salut Universitat de Barcelona Barcelona Spain

Faculty of Medicine University of Porto Portugal

Gastroenterology 2nd Department of Internal Medicine University Hospital Hradec Kralove Faculty of Medicine in Hradec Kralove Charles University of Prague Czech Republic

Gastroenterology and Clinical Research Unilabs Portugal

Gastroenterology Department Centro Hospitalar do Porto Porto Portugal

Gastroenterology Department Centro Hospitalar S João Porto Portugal

Gastroenterology Department ICMDM Hospital Clínic Universitat de Barcelona Barcelona Spain

Gastroenterology Department Portuguese Institute of Oncology of Porto Porto Portugal

Gastroenterology Department Portuguese Oncology Institute of Coimbra Coimbra Portugal

Hepatogastroenterology Unit 2nd Department of Internal Medicine Propaedeutic Medical School National and Kapodistrian University of Athens Attikon University General Hospital Athens Greece

INSERM Center for Research in Transplantation and Translational Immunology University of Nantes Nantes France

Institute of Biomedical Sciences Abel Salazar University of Porto Porto Portugal

Institute of Molecular Pathology and Immunology at the University of Porto Porto Portugal

Instituto de Investigação e Inovação em Saúde University of Porto Porto Portugal

Instituto de Investigaciones Biomédicas August Pi i Sunyer Barcelona Spain

IRCCS Humanitas Research Hospital Rozzano Milan Italy

Lee Kong Chian School of Medicine Nanyang Technological University Singapore

Medical Research Council Translational Immune Discovery Unit Radcliffe Department of Medicine University of Oxford Oxford UK

Otto von Guericke University Magdeburg Germany

Pathology Department Centro Hospitalar de São João and Faculty of Medicine Porto Portugal

Precancerous Lesions and Early Cancer Management Group Research Center of IPO Porto Porto Portugal

Public Health and Forensic Sciences and Medical Education Department Faculty of Medicine University of Porto Porto Portugal

Translational Gastroenterology and Liver Unit Nuffield Department of Medicine John Radcliffe Hospital University of Oxford Oxford UK

University College London London United Kingdom

University of Porto Institute of Molecular Pathology and Immunology of the University of Porto Porto Portugal

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