Gastric Cancer Risk in Patients with Intestinal Metaplasia: Long-Term Outcomes from a Large Single-Center Cohort in Türkiye

<b>Background/Objectives:</b> Gastric intestinal metaplasia (GIM) is a recognized premalignant condition for gastric cancer (GC), but long-term outcomes and predictors of progression remain incompletely understood. This study aimed to evaluate the progression of GIM and identify factors associated with malignant transformation. <b>Methods:</b> In this retrospective single-center study, 1204 adult patients with histologically confirmed GIM and at least 12 months of follow-up after esophagogastroduodenoscopy (EGD) were analyzed. Clinical and pathological variables, including GIM extent, <i>Helicobacter pylori</i> status, family history of GC, demographic factors, and residence in endemic regions, were assessed. Patients were stratified into high- and low-risk groups according to established criteria, and progression to GC or other neoplasms was recorded. <b>Results:</b> During a mean follow-up of 38.6 months, 49.1% of patients had no detectable GIM at the end of follow-up, 48.7% remained unchanged, and 2.2% showed disease progression. Among progressed cases, adenocarcinoma accounted for 66.7%, dysplasia for 29.6%, and SCC for 3.7%. Progression was significantly more common among males, older patients, and those with antrum + corpus involvement. The overall progression rate from GIM to adenocarcinoma was 1.5% (approximately 0.45% per patient-year). No significant difference in progression or survival was observed between high- and low-risk groups. <b>Conclusions:</b> The long-term malignant transformation rate of GIM is low. Male sex and extensive gastric involvement were associated with higher progression rates, while <i>H. pylori</i> was not predictive of malignant transformation. These findings support individualized surveillance strategies for patients with GIM, while routine surveillance of antrum-limited GIM may provide minimal benefit but increase healthcare burden.