Assessment of the Accuracy and Clinical Impact of the Preoperative Histopathology of Resected Early Gastric Cancers

Background/Objectives: Superficial gastric neoplasms, including dysplasia and early adenocarcinoma, are increasingly managed by endoscopic submucosal dissection (ESD). Preoperative assessment relies on endoscopic forceps biopsy (EFB), despite its limited ability to predict final histology. The diagnostic value of repeat biopsy, the influence of the endoscopy setting where biopsies were taken, and the clinical relevance of histologic discrepancies remain incompletely defined. Methods: We conducted a retrospective, single-center study of 270 superficial gastric lesions resected by ESD between 2015 and 2024. Histologic concordance between EFB and ESD was evaluated, including comparisons between initial and repeated biopsies, and between community- and hospital-based settings. Multivariable models identified predictors of histologic discrepancy and assessed the impact of underestimation on curative resection. The association between biopsy repetition and submucosal fibrosis was also explored. Results: Histologic concordance between EFB and ESD was 54.1%, with underestimation in 41.1% and severe underestimation in 8.9%. Repeat biopsy improved concordance from 39.3% to 60.7% (p = 0.007) and increased adenocarcinoma sensitivity from 12.5% to 56.3%, without increasing submucosal fibrosis. Hospital-based biopsies outperformed community-based ones across all diagnostic metrics. In multivariable analysis, older age and larger lesion size were independent predictors of discrepancy. Histologic underestimation was independently associated with a lower likelihood of curative resection (OR = 0.148; p = 0.003), although only six lesions ultimately exceeded formal ESD criteria due to undetected high-risk features. Conclusions: EFB frequently underestimates histological severity in superficial gastric neoplasia. Repeat biopsy and centralized evaluation significantly improve diagnostic accuracy without increasing procedural risk. However, the role of biopsy lies primarily in excluding high-risk features rather than providing definitive staging. In this context, ESD serves not only as curative therapy but also as a key diagnostic step for accurate staging and treatment planning.