Bogdan Oprea
Background and Objectives: Immunohistochemistry (IHC) is a keystone in gastric cancer (GC) management, allowing treatment customization, including for advanced or metastatic diseases. This review aims to evaluate the critical role of IHC markers, analyzing their efficiency in molecular subclassification and prediction of response to gastric cancer-targeted therapies, while also describing state-of-the-art IHC techniques and perspectives. Results: The major challenges for the GC management were structured in two main sections, as follows: (i) the current paradigm of gastric neoplasia diagnosis, which includes subsections related to the methodological and morphological foundations, the epidemiological dynamics, and risk factors, as well as differential diagnosis of poorly differentiated tumors; and (ii) the progress in 3,3′-diaminobenzidine (DAB) application and advanced reagents in gastric cancer immunohistochemistry. Discussion: Considering the role of IHC and DAB, the following topics were successively addressed in seven sections: GC key biomarkers, such as human epidermal growth factor receptor 2 (HER2), programmed death-ligand 1 (PD-L1), and DNA replication mismatch repair (MMR) system, allow direct correlation between tissue morphology and protein expression; intestinal and gastrointestinal differentiation markers; emerging and aggressive histological subtypes; epithelial–mesenchymal transition, E-cadherin, and the process of tumor budding; implementation of innovative procedures in gastric cancer immunohistochemistry; and automation, quality control, and sustainability in the pathology laboratory. Perspectives: The main directions were focused on the integration of artificial intelligence (AI) algorithms for digital quantification of the IHC signal and also on the expansion of panels to new targets, such as Claudin 18.2 (CLDN 18.2), which redefines treatment approaches in advanced stages. Conclusions: Although faced with technical and biological limitations, immunohistochemistry remains indispensable in modern gastric oncology. The evolution towards digital pathology and the refinement of scoring criteria will transform IHC from a complementary test into a visual tool that is essential for personalizing oncological treatment.