A retrospective study compared the diagnostic accuracy of conventional forceps biopsy (CFB) and endoscopic submucosal dissection (ESD) for gastric epithelial neoplasia (GEN). From 2009 to 2015, 444 patients underwent ESD, and their CFB and ESD results were analyzed. The concordance rate between CFB and ESD was 68.92%. Men had a lower concordance rate (63.61% vs 79.33%) and were older than concordant patients (P=0.048). Multivariate analysis showed that men had a lower concordance rate (coefficient -0.730, P=0.002) and a higher rate of pathological upgrade (coefficient -0.648, P=0.015). Locations of CFB did not affect concordance rate. The concordance rate was relatively high in the hospital. Old men with CFB in the gastric fundus or antrum were strongly suggested to undergo ESD if precancerous lesions were found. Young women with low-grade intraepithelial neoplasia (LGIN) could select regular follow-up. The study found that gastric antrum was the major location of precancerous lesions and cancers, while the gastric fundus had a high proportion of discordance rate and upgrade of pathological results. Therefore, old men plus gastric fundus or antrum of CFB were strongly suggested to perform ESD if precancerous lesions were found. Young women with LGIN could select regular follow-up. The study also noted that CFB may underestimate the possibility of coexisting HGIN or cancer. The cost-benefit ratio of ESD treatment was lower than CFB. Endoscopic resection is strongly recommended for HGIN due to the high possibility of evolving into adenocarcinoma. The study had limitations, including potential selective bias and lack of standardized criteria for next treatment. A further large-scale prospective study is needed to overcome these limitations.A retrospective study compared the diagnostic accuracy of conventional forceps biopsy (CFB) and endoscopic submucosal dissection (ESD) for gastric epithelial neoplasia (GEN). From 2009 to 2015, 444 patients underwent ESD, and their CFB and ESD results were analyzed. The concordance rate between CFB and ESD was 68.92%. Men had a lower concordance rate (63.61% vs 79.33%) and were older than concordant patients (P=0.048). Multivariate analysis showed that men had a lower concordance rate (coefficient -0.730, P=0.002) and a higher rate of pathological upgrade (coefficient -0.648, P=0.015). Locations of CFB did not affect concordance rate. The concordance rate was relatively high in the hospital. Old men with CFB in the gastric fundus or antrum were strongly suggested to undergo ESD if precancerous lesions were found. Young women with low-grade intraepithelial neoplasia (LGIN) could select regular follow-up. The study found that gastric antrum was the major location of precancerous lesions and cancers, while the gastric fundus had a high proportion of discordance rate and upgrade of pathological results. Therefore, old men plus gastric fundus or antrum of CFB were strongly suggested to perform ESD if precancerous lesions were found. Young women with LGIN could select regular follow-up. The study also noted that CFB may underestimate the possibility of coexisting HGIN or cancer. The cost-benefit ratio of ESD treatment was lower than CFB. Endoscopic resection is strongly recommended for HGIN due to the high possibility of evolving into adenocarcinoma. The study had limitations, including potential selective bias and lack of standardized criteria for next treatment. A further large-scale prospective study is needed to overcome these limitations.