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:

---

### **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.

---

### **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.

---

### **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.

---

### **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).**

---

### **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.

---

### **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.

---

### **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.

---

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.