MAPS III guideline updates

The MAPS III guideline updates, set for 2025, provide comprehensive, pragmatic, and risk-stratified recommendations for the detection, staging, treatment, and surveillance of gastric precancerous conditions and early gastric neoplasia. Below is a detailed summary of the updates:

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1. Screening Recommendations:

• Population-Level Screening:

• Endoscopic screening is suggested every 2–3 years in high-risk regions (age-standardized incidence rate [ASR] >20 per 100,000).

• In intermediate-risk regions, screening every 5 years may be considered if it is cost-effective.

• Screening is not recommended in low-risk regions.

• Individual Risk Assessment:

• Regardless of geographic origin, individual gastric cancer risk assessment is recommended at the time of the first gastroscopy.

• Screening or surveillance beyond the age of 80 years is generally discouraged, although patient-specific comorbidities should be considered when planning treatment.

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2. Endoscopy and Biopsy Techniques:

• High-Quality Endoscopy:

• Use of virtual chromoendoscopy (with appropriate training) is recommended for:

• Detection of gastric lesions.

• Targeted biopsies.

• Staging of atrophic gastritis and intestinal metaplasia.

• Post-therapy surveillance.

• Biopsy Strategy:

• Random biopsies are only recommended when no visible endoscopic abnormalities are detected.

• Suggested biopsy sampling involves:

• Two vials with 2 biopsies each from the antrum/incisura and the corpus.

• Advanced Imaging:

• Routine advanced imaging (e.g., EUS, CT, MRI, or PET-CT) before endoscopic resection is not recommended unless:

• Deep invasion is suspected.

• The suitability of endoscopic resection is uncertain.

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3. Treatment Recommendations:

• Endoscopic Resection:

• Endoscopic submucosal dissection (ESD) is recommended for most differentiated dysplastic or intramucosal cancers, based on size and ulceration criteria.

• Endoscopic mucosal resection (EMR) may be an option for small, low-risk lesions.

• Post-Resection Management:

• Clear histology-based pathways are outlined:

• Curative/Very Low-Risk Lesions: Typically require no further treatment.

• Curative/Low-Risk Lesions: May need further staging or multidisciplinary discussion.

• Local-Risk Lesions: Favor endoscopic surveillance or re-treatment.

• High-Risk Lesions (e.g., deep invasion, lymphovascular invasion [LVI], positive vertical margins, large/ulcerated or poorly differentiated tumors): Require staging and multidisciplinary evaluation for additional therapy.

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4. Staging Systems:

• Validated endoscopic grading systems are endorsed for staging gastric precancerous conditions and neoplasia:
• Kimura–Takemoto classification.
• EGGIM (Endoscopic Grading of Gastric Intestinal Metaplasia).
• OLGA (Operative Link on Gastritis Assessment).
• OLGIM (Operative Link on Gastric Intestinal Metaplasia Assessment).

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5. H. pylori Management:

• H. pylori Eradication:
• Strongly recommended for:
• Patients with precancerous conditions (e.g., atrophic gastritis or intestinal metaplasia).
• Patients who have undergone therapy for gastric precancerous lesions or early gastric cancer.

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6. Lifestyle and Preventive Measures:

• Patients should be advised to stop smoking, as it is a risk factor for gastric cancer.
• Low-dose aspirin may be considered for cancer prevention in selected individuals who are at high cardiovascular risk.

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Key Considerations:

• The guidelines emphasize personalized risk assessment and evidence-based approaches for surveillance and treatment.
• Screening and surveillance should be tailored to the patient's age, risk factors, and comorbidities, with a focus on avoiding unnecessary procedures in low-risk groups or elderly patients.
• The use of advanced endoscopic techniques and validated staging systems ensures the accurate detection and management of gastric precancerous conditions.

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In summary, the 2025 MAPS III guidelines aim to optimize the early detection and management of gastric precancerous conditions and early cancer through risk stratification, high-quality endoscopic techniques, and individualized care plans. These updates reflect the latest evidence and advancements in gastric cancer prevention and treatment.