Optimizing immunotherapy in advanced gastric cancer: established and emerging biomarkers for precision patient...

mmune checkpoint inhibitors have reshaped the therapeutic landscape of advanced gastric and gastroesophageal junction cancer, yet durable benefit remains restricted to biologically selected patient subgroups. Optimizing immunotherapy, therefore, requires a disease-specific, clinically practical, and critically interpreted biomarker framework rather than reliance on any single predictive marker. This review synthesizes established and emerging biomarkers for immune checkpoint inhibitor selection in advanced, metastatic, and perioperative gastric cancer, with emphasis on programmed death-ligand 1 combined positive score, deficient mismatch repair/microsatellite instability-high status, tumor mutational burden, Epstein-Barr virus-associated tumors, HER2-defined combination strategies, tumor microenvironment features, circulating tumor DNA dynamics, and artificial intelligence-assisted models. In addition to summarizing biological rationale, this review critically evaluates trial-based limitations that influence biomarker interpretation, including assay variability, spatial and temporal heterogeneity, dynamic PD-L1 expression, inconsistent CPS thresholds, overlap between TMB-high and MSI-H biology, and the limited prospective validation of exploratory markers. Recent perioperative and neoadjuvant ICI studies are discussed to highlight how early biomarker testing may guide treatment intensification, de-escalation, or trial selection in resectable disease. Emerging evidence supporting TMEscore, longitudinal ctDNA response, and multimodal AI-based prediction is also examined, with an emphasis on the current barriers to routine clinical implementation. Finally, this review proposes a tiered, resource-aware interpretation of biomarkers that distinguishes clinically actionable markers from investigational tools and addresses challenges related to standardization, cost, access, and equity. Overall, biomarker-guided integration of molecular, immune, dynamic, and translational markers is essential to improve patient selection and advance precision immunotherapy in gastric cancer.