Guideline sources The following summarized guidelines for the evaluation and management of gastric cancer are prepared by our editorial team based on guidelines from the Society for Immunotherapy of Cancer (SITC 2023), the American College of Gastroenterology (ACG 2023; 2017; 2015), the American Society of Clinical Oncology (ASCO 2023), the European Society of Medical Oncology (ESMO 2022), the British Society of Gastroenterology (BSG 2022; 2019), the European Reference Network on Genetic Tumour Risk Syndromes (GENTURIS/EURACAN/ESMO 2022), the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS 2021), the European Society of Gastrointestinal Endoscopy (ESGE 2021; 2017), the American Society for Gastrointestinal Endoscopy (ASGE 2021; 2017; 2015), the American Gastroenterological Association (AGA 2020), the European Society of Gastrointestinal Endoscopy (ESGE/ESP/SPED/EHMSG 2019), the European Reference Network on Rare Adult Solid Cancers (EURACAN/ESMO 2018), the British Sarcoma Group (BSG 2017), and the American Society for Clinical Pathology (ASCP/CAP/ASCO 2017). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 https://web.pathway.md/diseases/recTVyH1TVJCJ34JE 1/13 6/24/23, 2:55 AM Gastric cancer Pathway Guidelines 1. Screening and diagnosis Indications for screening (asymptomatic patients): obtain population-based endoscopic screening in asymptomatic persons only in regions with a very high incidence of gastric cancer. B Indications for screening, familial cancer syndromes: As per ESMO 2022 guidelines, refer patients with suspected familial cancer syndrome to a geneticist for assessment. B As per ACG 2015 guidelines, consider screening for gastric cancer in patients at risk for or affected with Lynch syndrome by baseline upper gastrointestinal endoscopy with gastric biopsy at age 30-35 years. Consider obtaining ongoing surveillance every 3-5 years if there is a family history of gastric or duodenal cancer. C 2. Classification and risk stratification Staging: perform a physical examination, obtain CBC with differential, liver and renal function tests, contrast-enhanced CT of the chest, abdomen pelvis, and perform upper gastrointestinal endoscopy for initial staging and risk assessment. B Show 2 more 3. Diagnostic investigations Testing for Helicobacter pylori infection: test for H. pylori infection in all patients with low-grade gastric MALT lymphoma, or a history of endoscopic resection of early gastric cancer. B Show 2 more 4. Diagnostic procedures Upper gastrointestinal endoscopy: Perform urgent endoscopy only in the following patients if no other upper gastrointestinal alarm symptoms or signs are reported: age 55 years, dyspepsia and weight loss age > 40 years, coming from an area at an increased risk of gastric cancer or having a family history of gastroesophageal cancer. B Biopsy: As per ESGE 2021 guidelines, take at least 6 biopsies in patients with suspected advanced gastric cancer. B Show 3 more https://web.pathway.md/diseases/recTVyH1TVJCJ34JE 2/13 6/24/23, 2:55 AM Gastric cancer Pathway As per ESGE 2017 guidelines, consider performing EUS-guided sampling aiming at a core biopsy after the failure of standard biopsy techniques in patients with diffuse gastric wall thickening. Consider using newly developed biopsy techniques under optical endoscopic guidance as an alternative. C Show 3 more Histopathology: Make the diagnosis from multiple (5-8) endoscopic biopsies to guarantee an adequate representation of the tumor. B Report the histological diagnosis according to the WHO criteria. B Ancillary testing: As per SITC 2023 guidelines, obtain tumor testing for PD-L1 expression B and high MSI/MMR deficiency status in all patients with esophagogastric cancer. B Use the CPS to quantify PD-L1 expression in patients with esophagogastric adenocarcinoma. B Consider obtaining MSI status testing by next-generation sequencing. Consider obtaining MMR status testing by immunohistochemistry. Show 3 more As per ESMO 2022 guidelines, assess HER2 expression by immunohistochemistry and/or amplification by in situ hybridization, PD-L1 by immunohistochemistry according to CPS, A and MSI-high/MMR deficiency B as validated predictive biomarkers for drug therapy. A As per CAP 2017 guidelines: Obtain HER2 testing on tumor tissue in patients with advanced gastric adenocarcinoma being potential candidates for HER2-targeted therapy. A Obtain HER2 testing on tumor tissue of the biopsy or resection specimens (primary or metastasis), if such specimens are available and adequate, or on FNA specimens (cell blocks) as an acceptable alternative, preferably before initiating trastuzumab therapy. B Diagnostic laparoscopy and peritoneal lavage: perform diagnostic laparoscopy and peritoneal washings for cytology in patients with resectable gastric cancer being also candidates for perioperative chemotherapy. B Recognize that patients with positive lavage cytology are uncertain candidates for curatively-intended surgical resection. 5. Medical management General principles: ensure multidisciplinary treatment planning before any treatment decision. B Management of locoregional disease (perioperative chemotherapy): offer perioperative (pre- and postoperative) chemotherapy in patients with stage IB resectable gastric cancer. A Show 3 more Management of locoregional disease (adjuvant chemoradiotherapy): offer adjuvant chemotherapy in patients with stage IB gastric cancer undergone surgery without administration of preoperative chemotherapy. A Show 5 more https://web.pathway.md/diseases/recTVyH1TVJCJ34JE 3/13 6/24/23, 2:55 AM Gastric cancer Pathway Management of advanced/metastatic disease (first-line chemotherapy): offer first-line chemotherapy with a platinum and a fluoropyrimidine, and prefer oxaliplatin, especially for older patients. A Show 2 more Management of advanced/metastatic disease, targeted therapy and immunotherapy: As per ASCO 2023 guidelines, offer nivolumab in combination with fluoropyrimidine- and platinum-based chemotherapy as first-line therapy in HER2-negative patients with gastric adenocarcinoma and PD-L1 CPS 5. B Show 3 more As per SITC 2023 guidelines, do not offer single-agent immune checkpoint inhibitor therapy in patients with untreated, advanced, microsatellite stable/MMR-proficient esophagogastric cancer. Consider offering single-agent anti-PD-1 therapy as an option in patients with untreated, advanced, high MSI/MMR-deficient esophagogastric cancer ineligible for chemotherapy. D Show 2 more As per ESMO 2022 guidelines, offer trastuzumab-chemotherapy in patients with HER2-positive tumors. A Show 7 more As per ASCO/ASCP/CAP 2017 guidelines, offer combination chemotherapy and HER2-targeted therapy as initial treatment in appropriate patients with HER2-positive advanced gastric adenocarcinoma. B Management of advanced/metastatic disease (liver metastasis): Offer systemic adjuvant therapy in patients with liver metastases from gastric cancer. B Offer adjuvant imatinib after hepatectomy in patients with liver metastases from gastrointestinal stromal tumors. B Palliative care: offer early palliative care referral and nutritional support to patients with gastric cancer. A 6. Nonpharmacologic interventions Nutritional support: offer dietary support with attention to vitamin and mineral deficiencies in patients with gastric cancer. B 7. Therapeutic procedures Endoscopic gastroduodenal stenting: consider placing self-expandable metallic stents or performing surgical gastrojejunostomy in patients with incurable malignant gastric outlet obstruction undergoing palliative intervention. Decide between these approaches based on patient characteristics and preferences, multidisciplinary input, and local expertise. C Show 2 more https://web.pathway.md/diseases/recTVyH1TVJCJ34JE 4/13 6/24/23, 2:55 AM Gastric cancer Pathway 8. Perioperative care Patients with hereditary diffuse gastric cancer: Include the following in the management of patients with hereditary diffuse gastric cancer: prophylactic gastrectomy after age 20 years (> 80% risk by age 80) breast cancer surveillance in females beginning at age 35 years with annual mammography and breast MRI and clinical breast examination every 6 months colonoscopy beginning at age 40 years in families including colon cancer. B 9. Surgical interventions Surgical resection (locoregional disease): consider performing endoscopic or surgical resection alone in selected patients with very early tumors (stage IA). C Show 2 more Surgical resection, advanced/metastatic disease: As per ESMO 2022 guidelines: Do not offer gastrectomy in patients with metastatic gastric cancer unless required for palliation of symptoms. D Do not offer resection of metastases in general, but consider offering individually in highly selected patients with oligometastatic disease responsive to chemotherapy. D As per JSHBPS 2021 guidelines: Do not perform hepatectomy in patients with liver metastases from gastric cancer. D Perform hepatectomy with curative intent in patients with liver metastases from G1/G2 gastroenteropancreatic NETs. B Palliative gastrojejunostomy: Consider performing surgical gastrojejunostomy or placing self-expandable metallic stents in patients with incurable malignant gastric outlet obstruction undergoing palliative intervention. Decide between these approaches based on patient characteristics and preferences, multidisciplinary input, and local expertise. C Consider preferring surgical gastrojejunostomy in patients with a life expectancy of > 6 months and good performance status. 10. Specific circumstances Patients with precancerous gastric lesions (etiology): Recognize that: patients with chronic atrophic gastritis or intestinal metaplasia are at risk for gastric adenocarcinoma A patients with advanced stages of gastritis, that is, atrophy and/or intestinal metaplasia affecting both antral and corpus mucosa, are at higher risk for gastric adenocarcinoma B https://web.pathway.md/diseases/recTVyH1TVJCJ34JE 5/13 6/24/23, 2:55 AM Gastric cancer Pathway histologically confirmed intestinal metaplasia is the most reliable marker of atrophy in gastric mucosa. A Recognize that the management of patients with chronic atrophic gastritis or intestinal metaplasia intends to prevent high-grade dysplasia and invasive carcinoma. B Patients with precancerous gastric lesions, upper GI endoscopy: As per BSG 2019 guidelines, perform a full systematic endoscopy (examination time of a minimum of 7 minutes) of the stomach with clear photographic documentation of gastric regions and pathology in patients at higher risk for gastric adenocarcinoma, including atrophic gastritis and gastric intestinal metaplasia. B Show 10 more As per SPED/ESP/EHMSG/ESGE 2019 guidelines, perform endoscopy in patients with advanced stages of atrophic gastritis, particularly if H. pylori serology is negative. B Show 3 more As per ASGE 2017 guidelines, consider regarding a firm, round subepithelial lesion with central umbilication along the greater curve of the antrum of the stomach as diagnostic for a pancreatic rest. C Patients with precancerous gastric lesions, endoscopic ultrasound: As per ACG 2023 guidelines, consider performing EUS for the diagnosis of nonlipomatous subepithelial lesions. C Show 2 more As per ASGE 2017 guidelines: Consider performing EUS to further characterize indeterminate subepithelial lesions. C Do not perform further EUS for a pancreatic rest. D As per ASGE 2015 guidelines, perform EUS with or without FNA in the evaluation of gastric submucosal lesions. A Patients with precancerous gastric lesions, biopsy: As per ACG 2023 guidelines, avoid performing bite-on-bite biopsies in the evaluation of subepithelial lesions before an EUS. D Show 2 more As per BSG 2019 guidelines, perform biopsy to confirm the diagnosis in patients with image- enhanced features of chronic atrophic gastritis. Direct biopsies at mucosal sites within Sydney protocol areas where enhanced imaging discloses gastric intestinal metaplasia. Collect biopsy samples in separate containers and label them as either 'directed' or 'random' to corroborate the endoscopic staging assessment. B Show 3 more As per SPED/ESP/EHMSG/ESGE 2019 guidelines, perform gastric biopsies both for H. pylori infection diagnosis and identification of advanced stages of atrophic gastritis during the first diagnostic upper gastrointestinal endoscopy, to adequately stage gastric precancerous conditions. B Show 2 more https://web.pathway.md/diseases/recTVyH1TVJCJ34JE 6/13 6/24/23, 2:55 AM Gastric cancer Pathway As per ASGE 2017 guidelines, consider performing FNA or fine needle biopsy of lesions arising from the muscularis propria for histologic evaluation. C As per ASGE 2015 guidelines, perform biopsy or resection of solitary gastric polyps when possible. A Show 4 more Patients with precancerous gastric lesions (serum pepsinogen levels): assess serum pepsinogen I level and serum pepsinogen I/II ratio to identify patients with advanced stages of atrophic gastritis, and perform endoscopy in these patients, particularly if H. pylori serology is negative. B Patients with precancerous gastric lesions, H. pylori eradication: As per AGA 2020 guidelines, test for and eradicate H. pylori infection in patients with gastric intestinal metaplasia. B As per BSG 2019 guidelines: Initiate H. pylori eradication therapy to reduce the risk of gastric adenocarcinoma development in patients with atrophic gastritis. A Consider initiating H. pylori eradication therapy to reduce the risk of developing gastric adenocarcinoma in patients with H. pylori-associated gastric intestinal metaplasia or dysplasia. B As per SPED/ESP/EHMSG/ESGE 2019 guidelines, initiate H. pylori eradication therapy for the management of non-atrophic chronic gastritis, regression of atrophic gastritis, and to reduce the risk of gastric cancer in patients with non-atrophic and atrophic gastritis. A Show 2 more Patients with precancerous gastric lesions, NSAIDs: As per BSG 2019 guidelines, do not use NSAIDs or COX-2 inhibitors to reduce the risk of progression of premalignant lesions of the stomach. D As per SPED/ESP/EHMSG/ESGE 2019 guidelines: Do not use COX-1 or COX-2 inhibitors to slow the progression of gastric precancerous conditions. D Consider offering daily low-dose aspirin for the prevention of various cancers, including gastric cancer, in selected patients. C Patients with precancerous gastric lesions (antioxidants): do not use antioxidants to reduce the prevalence of premalignant gastric lesions. D Patients with precancerous gastric lesions, endoscopic resection: As per ACG 2023 guidelines, consider performing endoscopic mucosal resection or endoscopic submucosal dissection for the resection of type 1 gastric NETs. C Show 2 more As per BSG 2019 guidelines, perform en bloc resection of all gastric dysplasia and early gastric adenocarcinoma. Recognize that an endoscopic mucosal resection technique can achieve en https://web.pathway.md/diseases/recTVyH1TVJCJ34JE 7/13 6/24/23, 2:55 AM Gastric cancer Pathway bloc excision for lesions 10 mm in size, but only an endoscopic submucosal dissection technique can ensure en bloc excision for lesions > 10 mm in size. A Show 3 more As per ASGE 2015 guidelines: Perform endoscopic resection and surveillance endoscopy in patients with confirmed gastric intestinal metaplasia with high-grade dysplasia when feasible. B Consider performing polypectomy of fundic gland polyps 1 cm, hyperplastic polyps 0.5 cm, and adenomatous polyps of any size when possible. C Patients with precancerous gastric lesions, surgical resection: As per ACG 2023 guidelines: Consider performing either submucosal tunneling endoscopic resection or surgical resection, when resection is necessary, for the management of subepithelial lesions originating from the muscularis propria layer of the esophagus and GEJ. C Insufficient evidence to recommend surveillance versus resection of gastric gastrointestinal stromal tumors < 2 cm in size. Consider resecting gastric gastrointestinal stromal tumors > 2 cm and all non-gastric gastrointestinal stromal tumors owing to their malignant potential. I As per ASGE 2017 guidelines: Perform surgery for gastric gastrointestinal stromal tumors > 2 cm in size or with high-risk features. B Consider removing lesions with malignant potential requiring treatment, either endoscopically or surgically, based on the type of lesion, size, location, patient preference, and available expertise. C Patients with precancerous gastric lesions, endoscopic surveillance: As per AGA 2020 guidelines: Avoid obtaining routine endoscopic surveillance in patients with gastric intestinal metaplasia. D Avoid performing a routine short-interval repeat endoscopy for risk stratification of patients with gastric intestinal metaplasia. D As per BSG 2019 guidelines, obtain endoscopic surveillance every 3 years in patients with extensive atrophic gastritis or gastric intestinal metaplasia, defined as affecting the antrum and body. B Show 4 more As per SPED/ESP/EHMSG/ESGE 2019 guidelines, perform immediate high-quality endoscopic reassessment with chromoendoscopy (virtual or dye-based) in patients with dysplasia in the absence of an endoscopically defined lesion. Perform biopsies for the staging of gastritis (if not previously done) and endoscopic surveillance within 6 months (if high-grade dysplasia) to 12 months (if low-grade dysplasia), if no lesion is detected in this high-quality endoscopy. B Show 6 more As per ASGE 2017 guidelines, consider obtaining surveillance with EUS for gastric gastrointestinal stromal tumors < 2 cm in size. C https://web.pathway.md/diseases/recTVyH1TVJCJ34JE 8/13 6/24/23, 2:55 AM Gastric cancer Pathway Show 2 more As per ASGE 2015 guidelines, consider performing endoscopy within 6 months of the diagnosis of pernicious anemia or the development of upper gastrointestinal symptoms in patients with pernicious anemia. C Show 3 more Patients with gastrointestinal stromal tumor (diagnosis): Make the diagnosis of gastrointestinal stromal tumor by a pathologist experienced in the disease. E Confirm the diagnosis before initiating neoadjuvant therapy with imatinib, since there is a wide differential. E Patients with gastrointestinal stromal tumor, endoscopic ultrasound: As per EURACAN/ESMO 2018 guidelines, obtain EUS and then follow-up in patients with gastric nodules < 2 cm. B As per BSG 2017 guidelines, obtain EUS in patients with lesions > 2 cm in diameter. E Patients with gastrointestinal stromal tumor, biopsy: As per GENTURIS/EURACAN/ESMO 2022 guidelines, perform resection if diagnosis of a gastrointestinal stromal tumor is made on biopsy unless major morbidity is expected. B As per EURACAN/ESMO 2018 guidelines, perform biopsy/excision in patients with tumors 2 cm. B As per BSG 2017 guidelines: Perform needle biopsy in patients with lesions > 2 cm in diameter, particularly if the lesion is in the stomach. E Consider performing percutaneous core needle biopsy if the tumor is inaccessible to EUS- guided biopsy. E Patients with gastrointestinal stromal tumor, mutational analysis: As per EURACAN/ESMO 2018 guidelines, obtain mutational analysis in the diagnostic work-up of patients with gastrointestinal stromal tumors (with the possible exclusion of < 2 cm non-rectal gastrointestinal stromal tumors). B As per BSG 2017 guidelines: Obtain mutational analysis and immunohistochemistry by an accredited laboratory for the diagnosis of gastrointestinal stromal tumors. E Obtain mutational analysis before neoadjuvant therapy since some gastrointestinal stromal tumors are insensitive to imatinib, such as patients with D842V mutation in exon 18 of PDGFRA. E Patients with gastrointestinal stromal tumor, chemotherapy, local/locoregional disease: As per GENTURIS/EURACAN/ESMO 2022 guidelines, consider offering neoadjuvant avapritinib in patients with PDGFRA-D842V mutation. B Show 2 more https://web.pathway.md/diseases/recTVyH1TVJCJ34JE 9/13 6/24/23, 2:55 AM Gastric cancer Pathway As per EURACAN/ESMO 2018 guidelines, offer neoadjuvant therapy with imatinib if R0 surgery with no expected major sequelae is not feasible. B Show 4 more As per BSG 2017 guidelines: Consider offering preoperative imatinib in patients with large gastric or rectal primaries where immediate resection is likely to be morbid, such as total gastrectomy or abdomino-perineal resection. E Offer adjuvant imatinib for 3 years in patients at high risk of recurrence or distant relapse, provided the tumor is not likely to be resistant to therapy (PDGFRA exon 18 mutation D842V). E Patients with gastrointestinal stromal tumor, chemotherapy, advanced/metastatic disease: As per GENTURIS/EURACAN/ESMO 2022 guidelines, offer imatinib 400 mg/day as first-line therapy in patients with locally advanced, inoperable, and metastatic disease, except for gastrointestinal stromal tumors without KIT/PDGFRA mutations or with a PDGFRA exon 18 D842V mutation. A Show 7 more As per EURACAN/ESMO 2018 guidelines, offer imatinib in patients with locally advanced inoperable and metastatic disease. A Show 7 more As per BSG 2017 guidelines, offer imatinib 400 mg/day in patients with unresectable or metastatic disease. Consider offering a larger dose of imatinib in patients with exon 9 mutation in KIT. E Show 2 more Patients with gastrointestinal stromal tumor (radiotherapy): consider offering radiotherapy as a palliative resource in selected patients with gastrointestinal stromal tumor. C Patients with gastrointestinal stromal tumor, surgical excision, local/locoregional disease: As per GENTURIS/EURACAN/ESMO 2022 guidelines, perform complete surgical excision of the lesion with no dissection of clinically negative lymph nodes in patients with localized gastrointestinal stromal tumor. B Show 2 more As per EURACAN/ESMO 2018 guidelines, perform complete surgical excision of the lesion, with no dissection of clinically negative lymph nodes, for the treatment of patients with localized gastrointestinal stromal tumor. B Show 2 more As per ASGE 2017 guidelines, perform surgery in patients with gastric gastrointestinal stromal tumors > 2 cm in size and in patients with high-risk features. B Patients with gastrointestinal stromal tumor, surgical excision, advanced/metastatic disease: As per EURACAN/ESMO 2018 guidelines: Individualize surgery of residual metastatic disease after making the decision with the patient in the case of uncertainty. B https://web.pathway.md/diseases/recTVyH1TVJCJ34JE 10/13 6/24/23, 2:55 AM Gastric cancer Pathway Consider performing surgical excision of progressing disease in individual patients with limited progression, while continuing imatinib. C As per BSG 2017 guidelines, consider performing surgery or other local measures, such as radiofrequency ablation, in patients with isolated progression. E Patients with gastrointestinal stromal tumor, surveillance imaging: As per GENTURIS/EURACAN/ESMO 2022 guidelines, obtain active surveillance in patients with gastrointestinal stromal tumor, if a biopsy is not feasible. B As per ASGE 2017 guidelines, consider obtaining surveillance EUS in patients with gastrointestinal stromal tumors < 2 cm in size. C As per BSG 2017 guidelines, obtain cross-sectional follow-up imaging in patients with a high- risk disease on adjuvant therapy at intervals of every 3-6 months during 3 years of treatment, 3 monthly for 2 years following cessation of treatment, and thereafter every 6 months for 3 years and annually for 5 years. E Show 2 more As per ASGE 2015 guidelines, consider obtaining annual EUS in patients with gastrointestinal stromal tumors < 2 cm to determine the progression of size or change in echo features, if surgical resection is not performed. C 11. Follow-up and surveillance Follow-up: obtain regular follow-up for investigation and treatment of symptoms, psychological support, and early detection of recurrence. B Show 3 more References 1. Banks M, Graham D, Jansen M et al. British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma. Gut. 2019 Sep;68 9 1545 1575. Open 2. F Lordick, F Carneiro, S Cascinu et al. Gastric cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol. 2022 Oct;33 10 1005 1020. Open 3. Sapna Syngal, Randall E Brand, James M Church et al. ACG clinical guideline: Genetic testing and management of hereditary gastrointestinal cancer syndromes. Am J Gastroenterol. 2015 Feb;110 2 223 62; quiz 263. Open 4. Pedro Pimentel-Nunes, Diogo Lib nio, Ricardo Marcos-Pinto et al. Management of epithelial precancerous conditions and lesions in the stomach MAPS II European Society of Gastrointestinal Endoscopy ESGE , European Helicobacter and Microbiota Study Group EHMSG , European Society of Pathology ESP , and Sociedade Portuguesa de Endoscopia Digestiva SPED guideline update 2019. Endoscopy. 2019 Apr;51 4 365 388. Open 5. Casali PG, Abecassis N, Aro HT et al. Gastrointestinal stromal tumours: ESMO EURACAN clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018 Oct 1;29 Suppl 4):iv68-iv78. Open https://web.pathway.md/diseases/recTVyH1TVJCJ34JE 11/13 6/24/23, 2:55 AM Gastric cancer Pathway 6. Ian Judson, Ramesh Bulusu, Beatrice Seddon et al. UK clinical practice guidelines for the management of gastrointestinal stromal tumours GIST . Clin Sarcoma Res. 2017 Apr 21;7 6. Open 7. Ronan J Kelly, Katherine Bever, Joseph Chao et al. Society for Immunotherapy of Cancer SITC clinical practice guideline on immunotherapy for the treatment of gastrointestinal cancer. J Immunother Cancer. 2023 Jun;11 6):e006658. Open 8. Angela N Bartley, Mary Kay Washington, Carol Colasacco et al. HER2 Testing and Clinical Decision Making in Gastroesophageal Adenocarcinoma: Guideline From the College of American Pathologists, American Society for Clinical Pathology, and the American Society of Clinical Oncology. J Clin Oncol. 2017 Feb;35 4 446 464. Open 9. Christopher J Black, Peter A Paine, Anurag Agrawal et al. British Society of Gastroenterology guidelines on the management of functional dyspepsia. Gut. 2022 Sep;71 9 1697 1723. Open 10. Brian C Jacobson, Amit Bhatt, Katarina B Greer et al. ACG Clinical Guideline: Diagnosis and Management of Gastrointestinal Subepithelial Lesions. Am J Gastroenterol. 2023 Jan 1;118 1 46 58. Open 11. Standards of Practice Committee, Ashley L Faulx, Shivangi Kothari et al. The role of endoscopy in subepithelial lesions of the GI tract. Gastrointest Endosc. 2017 Jun;85 6 1117 1132. Open 12. ASGE Standards of Practice Committee, John A Evans, Vinay Chandrasekhara et al. The role of endoscopy in the management of premalignant and malignant conditions of the stomach. Gastrointest Endosc. 2015 Jul;82 1 1 8. Open 13. Masakazu Yamamoto, Masahiro Yoshida, Junji Furuse et al. Clinical practice guidelines for the management of liver metastases from extrahepatic primary cancers 2021. J Hepatobiliary Pancreat Sci. 2021 Jan;28 1 1 25. Open 14. P G Casali, J Y Blay, N Abecassis et al. Gastrointestinal stromal tumours: ESMO EURACAN GENTURIS Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2022 Jan;33 1 20 33. Open 15. Roos E Pouw, Maximilien Barret, Katharina Biermann et al. Endoscopic tissue sampling Part 1 Upper gastrointestinal and hepatopancreatobiliary tracts. European Society of Gastrointestinal Endoscopy ESGE Guideline. Endoscopy. 2021 Nov;53 11 1174 1188. Open 16. Samir Gupta, Dan Li, Hashem B El Serag et al. AGA Clinical Practice Guidelines on Management of Gastric Intestinal Metaplasia. Gastroenterology. 2020 Feb;158 3 693 702. Open 17. Chey WD, Leontiadis GI, Howden CW et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2017 Feb;112 2 212 239. Open 18. Manish A Shah, Erin B Kennedy, Ashley E Alarcon-Rozas et al. Immunotherapy and Targeted Therapy for Advanced Gastroesophageal Cancer: ASCO Guideline. J Clin Oncol. 2023 Jan 5;JCO2202331. Open 19. ASGE Standards of Practice Committee, Terry L Jue, Andrew C Storm et al. ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction. Gastrointest Endosc. 2021 Feb;93 2 309 322.e4. Open 20. Jean-Marc Dumonceau, Pierre H Deprez, Christian Jenssen et al. Indications, results, and clinical impact of endoscopic ultrasound EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy ESGE Clinical Guideline Updated January 2017. Endoscopy. 2017 Jul;49 7 695 714. Open https://web.pathway.md/diseases/recTVyH1TVJCJ34JE 12/13 6/24/23, 2:55 AM Gastric cancer Pathway 21. ASGE Standards of Practice Committee, Early DS, Acosta RD et al. Adverse events associated with EUS and EUS with FNA. Gastrointest Endosc. 2013 Jun;77 6 839 43. Open 22. Muhammad Miftahussurur, Yoshio Yamaoka, David Y Graham. Helicobacter pylori as an oncogenic pathogen, revisited. Expert Rev Mol Med. 2017 Mar 21;19:e4. Open 23. E C Smyth, M Verheij, W Allum et al. Gastric cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2016 Sep;27(suppl 5):v38-v49. Open 24. N Stjepanovic, L Moreira, F Carneiro et al. Hereditary gastrointestinal cancers: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2019 Oct 1;30 10 1558 1571. Open 25. Kaveh Sharzehi, Amrita Sethi, Thomas Savides. AGA Clinical Practice Update on Management of Subepithelial Lesions Encountered During Routine Endoscopy: Expert Review. Clin Gastroenterol Hepatol. 2022 Nov;20 11 2435 2443.e4. Open https://web.pathway.md/diseases/recTVyH1TVJCJ34JE 13/13