Case of early gastric cancer with nodular gastritis

A case of depressed early gastric cancer with nodular gastritis is described. A 47‐year‐old Japanese man was referred to our hospital and admitted for surgical treatment of gastric cancer. Barium upper gastrointestinal study and endoscopy examination showed a 4.5 × 3.0 cm depressed lesion with a deep central ulceration in the anterior wall of the lower corpus. An unusual miliary pattern resembling ‘goose flesh’ was observed endoscopically in the antrum. Biopsy specimens from the tumor showed poorly differentiated adenocarcinoma, and specimens from the antrum showed many lymphoid follicles with a germinal center. Immunoglobulin G antibody and histological tests (Giemsa stain) for Helicobacter pylori were both positive. Early gastric cancer with nodular gastritis was diagnosed and a subtotal gastrectomy was performed. Histological examination of the resected specimen showed a stage I tumor infiltrating a poorly differentiated adenocarcinoma with a depressed lesion in the corpus (type 0 IIc + III) and nodular gastritis in the antrum. The patient is doing well 1 year after surgery.     

Advanced gastric cancer associated with nodular gastritis in a young patient

A 20-year-old female underwent an endoscopy for epigastralgia that revealed many small, elevated nodules in the antrum that were diagnosed as nodular gastritis. The endoscopy also showed an ulcerative lesion with an uneven round wall at the greater curvature of the middle corpus. Biopsy of the ulcerative lesion yielded a diagnosis of poorly differentiated adenocarcinoma. A distal gastrectomy was performed on the basis of a diagnosis of gastric cancer associated with nodular gastritis. The intraoperative findings revealed serosal invasion of the gastric cancer and the patient tested positive for peritoneal cytology. The pathological findings revealed poorly differentiated adenocarcinoma showing invasive growth with fibrosis on the corpus and large and superficial lymphoid follicles on the miliary nodules at the antrum. The patient was positive for Helicobacter pylori infection by both the serum Helicobacter pylori antibody and histopathological findings.     

A CASE OF DIFFUSE‐TYPE EARLY GASTRIC CANCER WITH NODULAR GASTRITIS

A 39‐year‐old woman was referred to Osaka Police Hospital and admitted for surgical treatment of gastric cancer. Barium upper gastrointestinal study and endoscopic examination showed a 3.0 × 3.0 cm depressed lesion in the greater curvature of the middle corpus. An unusual miliary pattern resembling ‘goose flesh’ was observed endoscopically in the antrum. Biopsy specimens from the tumor showed poorly differentiated adenocarcinoma, and specimens from the antrum showed many lymphoid follicles with a germinal center. Rapid urease test and histological tests (Giemsa stain) for Helicobacter pylori were both positive. Early gastric cancer with nodular gastritis (NG) was diagnosed and a partial gastrectomy was performed. Histological examination of the resected specimen showed a stage I tumor consisting mainly of signet‐ring cell carcinoma restricted to the mucosa. Postoperatively H. pylori eradication therapy was performed and proved to be successful. One year after eradication therapy, endoscopy with biopsy showed no recurrence of gastric cancer and the remarkable regression of antral NG.     

Conversion surgery after S-1 plus oxaliplatin combination chemotherapy for advanced gastric cancer with multiple liver metastases

Conversion therapy for gastric cancer is a new therapeutic concept. We report a case of a patient with advanced gastric cancer who underwent conversion surgery due to a remarkable regression of multiple liver metastases following chemotherapy. A 71-year-old man was referred to our hospital with gastric cancer. Esophagogastroduodenoscopy (EGD) revealed an irregular, nodular, ulcerated lesion in the lower third of the stomach. Analysis of biopsy specimens revealed a poorly differentiated adenocarcinoma. Abdominal contrast-enhanced computed tomography (CT) showed multiple liver mass lesions. The patient was clinically diagnosed with advanced gastric cancer with liver metastases and received S-1 plus oxaliplatin chemotherapy. After 6 cycles of chemotherapy, CT and magnetic resonance imaging showed complete resolution of the liver metastases, and EGD detected mucosal irregularities only. Since there was no evidence of further metastatic lesions in other organs, the patient underwent distal gastrectomy with D2 lymphadenectomy. The gross appearance of the surgically resected specimen showed a slightly elevated tumor measuring 4.5?×?3.5 cm. Pathological examination confirmed the diagnosis of a moderately differentiated gastric adenocarcinoma invading the muscularis propria with no lymph node metastases. The postoperative course was uneventful. The patient has continued to receive S-1 and oxaliplatin chemotherapy, and there has been no evidence of recurrence for 3 months following the operation. We propose that conversion therapy might be an effective treatment for patients with advanced gastric cancer; however, further studies and assessments are needed to confirm and establish this treatment strategy.     

Gastric adenocarcinoma of fundic gland (chief cell predominant type) coexisting with well differentiated intestinal adenocarcinoma: A case report

Rationale:Gastric adenocarcinoma of fundic gland (chief cell predominant type) (GA-FG-CCP) is a new, rare variant of gastric adenocarcinoma, which is characterized by mild nuclear atypia and specific immunohistochemical markers.Patient concerns:An 84-year-old Chinese man was referred to our hospital for endoscopic resection of a gastric lesion.Interventions:We performed endoscopic submucosal dissection, and successfully removed the lesion.Diagnosis:Esophago gastroduodenoscopy showed a slightly elevated lesion with a diameter of 22 mm in the posterior wall of cardia. Magnifying endoscopy with narrow band imaging revealed an abnormal microsurface and microvessels on the tumor surface. Endoscopic ultrasonography revealed a hypoechoic mass located in the first layer. The pathological diagnosis of the biopsy specimens indicated that the tumor was high grade intraepithelial neoplasia. The pathological diagnosis differed between the superficial and deeper part of the lesion. The superficial part was composed of a tubular structure with prominent atypia and was diagnosed as well differentiated intestinal adenocarcinoma. The deeper part was composed of a well-differentiated tubular adenocarcinoma mimicking the fundic gland cells, mainly the chief cells. The tumor cells showed mild nuclear atypia and was positive for pepsinogen-I (PG-I) and mucin-6 (MUC6). This deeper part was diagnosed as GA-FG-CCP.Outcomes:The tumor was successfully removed. This patient had no discomfort during the follow-up period (10 months).Lessons:We present a rare case of GA-FG-CCP coexisted with well-differentiated tubular adenocarcinoma. GA-FG-CCP exists in the deep mucosal layer and the muscularis mucosa, which could not be found under endoscopy, but could be discerned in pathology with mild nuclear atypia and special biomarkers.     

Phosphorylation of epidermal growth factor receptor and chromosome 7 polysomy in gastric adenocarcinoma

OBJECTIVE: To investigate the phosphorylation of epidermal growth factor receptor (EGFR) and its potentially associated chromosomal aberrations in gastric adenocarcinoma. METHODS: Phosphorylated EGFR (pEGFR) was detected by immunohistochemistry on 145 specimens including 60 tumoral, 60 non‐tumoral, 12 tumor‐adjacent intramucosal dysplasia from patients with gastric adenocarcinoma and 13 mucosae from cancer‐free patients. EGFR gene amplification and chromosome 7 (Chr‐7) polysomy were detected by fluorescence in situ hybridization. RESULTS: Positivity of pEGFR was found in 50 tumoral (83.3%) and 42 non‐tumoral specimens (70.0%). There was an association between tumoral and non‐tumoral zones on immunostains of pEGFR (r = 0.353, P = 0.006). Nuclear pEGFR usually presented in mucosae with Helicobacter pylori infection, stromal reaction or vascular invasion. Cytoplasmic pEGFR was correlated with local cancer extension (r = 0.337, P = 0.014) and inversely related with gastrokine 2, which had been previously detected in the same specimens. Eleven intramucosal dysplastic specimens were also positive for pEGFR while 13 mucosae from cancer‐free patients were all negative. No EGFR gene amplification was observed. However, seven tumor specimens showed Chr‐7 polysomy (11.7%) in which 5 were strongly positive for pEGFR. CONCLUSIONS: EGFR phosphorylation may be one of the mechanisms that promote tumor initiation and expansion in gastric adenocarcinoma. Detection of pEGFR with analysis of its nuclear or cytoplasmic patterns could be clinicopathologically valuable. Chr‐7 polysomy may partially contribute to EGFR activation in gastric adenocarcinoma, although its role does not predominate.     

GASTRIC ADENOCARCINOMA OF FUNDIC GLAND TYPE (CHIEF CELL PREDOMINANT TYPE) TREATED WITH ENDOSCOPIC ASPIRATION MUCOSECTOMY

Upper endoscopy screening in an asymptomatic 56‐year‐old man showed a small, yellowish elevated lesion with a central depression on the posterior wall in the gastric cardia. Biopsy specimens from this lesion were suspicious of carcinoid tumor. We suspected this lesion to be a sporadic gastric carcinoid tumor with a diameter of 5 mm, limited to the mucosal layer. We then performed an endoscopic aspiration mucosectomy with a cap‐fitted endoscope. Microscopically, the lesion obtained from the resected specimen was minimally invasive to the submucosa and showed highly differentiated columnar cells in irregularly anastomosing glands. Immunohistology was positive for pepsinogen‐I, and MUC6, partially positive for H⁺/K⁺‐ATPase, and negative for MUC5AC. In addition, it was positive for synaptophysin and CD56, and negative for chromogranin A. We finally diagnosed the patient as having gastric adenocarcinoma of fundic gland type (chief cell predominant type) with minimal invasion (100 µm) to the submucosa. Surveillance endoscopy with biopsy specimens and abdominal computed tomography at 1 year revealed no evidence of tumor recurrence. We herein report this rare case of gastric adenocarcinoma of fundic gland type (chief cell predominant type).     

A Case of Early Gastric Cancer Manifesting as a Submucosal Tumor

Abstract: Gastric cancer manifesting as a submucosal tumor (SMT) is not common. A gastric barium meal and endoscopic studies performed on a 49-year-old male with epigastric pain, revealed an elevated lesion with bridging folds and central depression on the posterior wall of the lower body. An endoscopic ultrasonography (EUS) revealed a hypoechoic mass lesion within the submucosal layer. Due to an increase in the size of the tumor and its central depression during the subsequent year and a half, the patient was admitted for closer examination. Endoscopic biopsy material from the deeper layer, obtained by mucosal resection, revealed a poorly differentiated adenocarcinoma. Microscopic examination of the resected stomach showed a poorly differentiated adenocarcinoma within the submucosal layer, with considerable lymphocyte infiltration. Immunohistological examination disclosed marked T cell infiltration adjacent to the cancer cells. We suggest that considerable lymphocyte infiltration, particularly T cells, may have some role in the protective reaction against cancer cells. Our case was diagnosed as being cancer 18 months after the first endoscopic study. The biopsy material taken from the depression at the time of the first examination showed benign findings and a EUS revealed typical SMT. In the case of SMT shown by EUS to be a hypoechoic mass lesion in the submucosal layer, it is recommended that biopsy material be obtained from the deeper layer using methods available such as artificial ulcer formation.     

Differentiated adenocarcinoma with a gastric phenotype in the stomach: difficulties in clinical and pathological diagnoses

Differentiated-type adenocarcinoma with gastric phenotype of the stomach is rare and is difficult to diagnose both clinically and pathologically. We report a case of differentiated-type adenocarcinoma with a gastric phenotype in the stomach. A 60-year-old Japanese female was referred to our hospital with gastric cancer. A barium meal examination and esophagogastroduodenoscopy revealed a granular elevated lesion in the lower body near the lesser curvature and a depressed lesion on the antrum. A biopsy specimen showed benign atrophic mucosa in a granulated lesion and moderately differentiated adenocarcinoma in the depressed lesion. The patient underwent laparoscopy-assisted distal gastrectomy with lymph node dissection. The postoperative course was uneventful. Histological examination of the resected tissue confirmed well-differentiated adenocarcinoma in the granulated lesion and moderately differentiated adenocarcinoma in the depressed lesion, without lymph node metastasis. Both lesions were confined to the mucosa. Since mucin immunohistochemistry revealed MUC5AC-positive staining in the granulated lesion, the final diagnosis was differentiated-type adenocarcinoma with gastric phenotype in the stomach. Despite the high malignant potential, the clinical and pathological diagnoses of gastric-type differentiated adenocarcinoma are often difficult. Mucin immunohistochemistry together with hematoxylin and eosin (HE) staining may be helpful in the pathological diagnosis of this rare disease.     

New subtype of gastric adenocarcinoma: mixed fundic and pyloric mucosa-type adenocarcinoma

A 73-year-old woman underwent upper endoscopic screening that revealed a 30-mm superficial elevated lesion in the anterior wall of the upper gastric body. The lesion had a whitish color and coarse granular surface in conventional white light endoscopy. Magnifying narrow-band imaging indicated irregular microvascular and microsurface patterns within a demarcation line. The microvessels had a distorted polygonal shape within the area surrounded by the marginal crypt epithelium. The patient underwent endoscopic resection. Histological examination of the resected specimen showed a very well- to well-differentiated tubular adenocarcinoma with differentiation toward the mixed fundic and pyloric mucosa, without chief cells. The histological and serological findings indicated the absence of Helicobacter pylori infection. The present case demonstrates a new histological subtype of gastric adenocarcinoma, which has characteristic endoscopic findings.     

Twelve-year natural history of a gastric adenocarcinoma of fundic gland type

A 77-year-old woman underwent an upper gastrointestinal (UGI) endoscopy screening examination, and a 10-mm reddish, submucosal tumor-like lesion was found on the posterior wall of the fornix. Biopsy was performed, but there was no evidence of malignancy, so annual follow-up by UGI endoscopy was decided upon. After 12 years, examination of another biopsy specimen revealed an adenocarcinoma of the fundic gland type. There had been no significant change in the size or shape of the lesion over the long follow-up period. Endoscopic submucosal dissection (ESD) was performed, and en bloc resection was achieved. Histopathologically, the tumor appeared as a flat elevated lesion measuring 11 × 10 mm. It was composed of irregularly shaped glands and invaded the submucosa up to 300 µm. Immunohistochemical examination involving specific antibodies to pepsinogen I, MIST-1, MUC6, and H⁺/K⁺-ATPase confirmed the fundic gland differentiation of the irregularly shaped glands together with a very low Ki-67 labeling index. Thus, gastric adenocarcinoma of the fundic gland type (GAFG) was diagnosed. Four years have passed since the ESD, and there has been no recurrence. To the best of our knowledge, this is the first report of the long-term natural history of GAFG. Over the 12 years, no morphologic changes were observed; the tumor remained within the submucosal layer. Our observations in this case strengthen the notion that GAFG is a specific type of gastric adenocarcinoma of low-grade malignancy.     

Gastric cancer following total proctocolectomy for colon cancer associated with ulcerative colitis

Here we report a case of advanced gastric cancer seen after total proctocolectomy for an early colon cancer associated with ulcerative colitis (UC). A 42-year-old man, diagnosed with UC at the age of 21, had undergone total proctocolectomy at the age of 38 for an early ascending colon cancer. Three years later the patient developed tarry stools and epigastric discomfort. Laboratory data showed anemia together with elevated serum p53 antibody. Gastric endoscopy showed thickening folds around a lesion in the stomach body. The pathological diagnosis was poorly differentiated adenocarcinoma with signet-ring cell carcinoma. Total gastrectomy was performed and the resected specimens showed a diffuse infiltrating tumor (scirrhous gastric carcinoma), 11 × 15 cm in size, with multiple lymph node metastases. Histopathological examination revealed diffuse infiltration of cancer cells throughout the gastric wall and invasion of the serosa. Results of cytology on abdominal lavage were positive for cancer cells. Likewise, immunohistochemical staining showed gastric mucin phenotype cancer cells positive for p53. In conclusion, it is important to bear in mind that patients with UC, especially chronically active pancolitis, potentially bear the risk of upper gastrointestinal complications.     

A case of mucin producing liver metastases with intrabiliary extension

A 75-year-old man was admitted to our hospital with a diagnosis of liver metastases from colon cancer. He underwent right hemicolectomy for cecal cancer eight years ago, and had a metastatic liver tumor in segment 8 (S8), which was surgically resected about 4 years after the initial operation. Histopathological examination of the resected specimens from both operations revealed a well-differentiated adenocarcinoma with mucinous carcinoma. Four months after the second operation, computed tomography demonstrated a low-density lesion at the cut surface of the remnant liver. Although it was considered to be a postoperative collection of inflammatory fluid, it formed a cystic configuration and increased in size to approximately 5 cm in diameter. With a tentative diagnosis of a recurrence of metastatic cancer, partial hepatectomy of S8 was performed. Histological examination of the resected specimens also revealed mucinous adenocarcinoma, which had invaded into the biliary ducts, replacing and extending along its epithelium. Immunohistochemically, the tumor cells were positive for cytokeratin (CK) 20, but negative for CK7. Therefore, the tumor was diagnosed as a metastatic adenocarcinoma from colonic cancer. Liver metastases of colorectal adenocarcinoma sometimes invade the Glisson's triad and grow along the biliary ducts.     

Gastric adenocarcinoma: pathomorphology and molecular pathology

Two types of gastric adenocarcinoma can be distinguished histopathologically: the diffuse and the intestinal type. Molecular pathology supports this theory by showing differences in the genetic pathways of both tumor types. In addition to known pathomorphological factors of prognosis, e.g., depth of tumor infiltration, number of lymph node metastases and resection margins, a few genes have been suggested to have prognostic impact in gastric carcinoma. Clinically relevant molecules whose expression or structure is altered include the plasminogen activator (uPA) and its inhibitor PAI-1 (plasminogen activator inhibitor type 1), the cell cycle regulator cyclin E, epidermal growth factor (EGF), the apoptosis inhibitor bcl-2, the cell adhesion molecule E-cadherin, and the multifunctional protein beta-catenin. Gene amplification and protein overexpression of the growth factor receptors c-erbB-2 and K-sam may be prognostic factors for intestinal-type and diffuse-type gastric cancer, respectively. In addition, genetic instability is commonly seen. There has long been evidence for a genetic predisposition to gastric cancer by epidemiological studies and case reports. Very recently, germ line mutations of E-cadherin have been identified that are responsible for a dominantly inherited form of diffuse-type gastric cancer and could be used to identify individuals that are at high risk. Received: 13 July 2000 / Accepted: 3 August 2000     

Prevalence and characteristics of post-gastroscopy gastric cancer: A retrospective study from an academic medical center

Background and Study AimsGastric cancer is diagnosed by endoscopy but false negative rates of up to 10% in the west and 40% in Asia have been reported. In Lebanon, little is known about the rates of post-gastroscopy gastric cancer (PGGC), defined as the proportion of patients diagnosed with gastric cancer with a negative previous examination within 2 years of diagnosis. We aimed to examine the rate of PGGC and its risk factors, clinico-pathologic and endoscopic characteristics at a University medical Center.Patients and MethodsRetrospective analysis of patients with histologically proven gastric malignancy over the last 14 years. Patients with history of upper endoscopy preceding the index diagnostic endoscopy by 6 to 24 months were included.Results18,976 patients underwent upper endoscopy and gastric cancer was diagnosed in 323 (1.7%). Of those, only 4 (1.2%) had a preceding endoscopy within 6 to 24 months of diagnosis: 3 adenocarcinoma and one MALT lymphoma. Upon review of the initial endoscopy, a mucosal abnormality had been noted in all 4 patients and biopsies taken in 3 were negative for cancer. The mean time to cancer diagnosis was 8 months (range 6–13 months).ConclusionA small proportion of gastric carcinomas are missed on endoscopy in this study. Patients with endoscopic evidence of mucosal abnormalities and negative biopsies should undergo repeat examination with multiple biopsies. Proper endoscopic technique, lesion recognition and adoption of performance improvement measures are important to optimize endoscopic practice.     

Successfully treated metachronous liver metastasis of alpha-fetoprotein-producing early gastric cancer: case report

We treated a 57-year-old male with liver metastasis derived from an alpha-fetoprotein-producing early gastric cancer. Eleven months after distal gastrectomy with D2 lymph node dissection, the patient underwent hepatectomy of segment 4 to resect a liver tumor 3 cm in diameter found by abdominal computed tomography. Immunohistochemical examination of the stomach and liver specimens, using anti-alpha-fetoprotein antibody, showed partial alpha-fetoprotein expression in both the primary gastric and metastatic hepatic tumors. The patient's serum alpha-fetoprotein level had been elevated at 302 ng/mL before hepatectomy, but the level remained below 5 ng/mL postoperatively. The patient remains alive without tumor recurrence 3 years after hepatectomy. There have been few previous reports of good outcome after curative resection of a metachronous liver metastasis derived from alpha-fetoprotein-producing gastric cancer. The assessment of serum alpha-fetoprotein level may be useful for detecting and monitoring liver metastasis in gastric cancer, especially for alpha-fetoprotein-producing tumors.     

A case of mucin producing liver metastases with intrabiliary extension

A 75-year-old man was admitted to our hospital with a diagnosis of liver metastases from colon cancer. He underwent right hemicolectomy for cecal cancer eight years ago, and had a metastatic liver tumor in segment 8 (S8),which was surgically resected about 4 years after the initial operation. Histopathological examination of the resected specimens from both operations revealed a welldifferentiated adenocarcinoma with mucinous carcinoma. Four months after the second operation, computed tomography demonstrated a low-density lesion at the cutsurface of the remnant liver. Although it was considered to be a postoperative collection of inflammatory fluid, it formed a cystic configuration and increased in size to approximately 5 cm in diameter. With a tentative diagnosis of a recurrence of metastatic cancer, partial hepatectomy of S8 was performed. Histological examination of the resected specimens also revealed mucinous adenocarci noma, which had invaded into the biliary ducts, replacing and extending along its epithelium. Immunohistochemically, the tumor cells were positive for cytokeratin (CK) 20, but negative for CK7. Therefore, the tumor was diagnosed as a metastatic adenocarcinoma from colonic cancer. Liver metastases of colorectal adenocarcinoma sometimes invade the Glisson's triad and grow along the biliary ducts.     

Benign gastric ulcer associated with Candida infection in a healthy adult

A case of benign gastric ulcer associated with Candida infection in a healthy adult is reported. The patient was a 46-year-old man complaining of epigastralgia. Endoscopic examination of the upper digestive tract revealed an elevated lesion with ulceration having an unclear border and thick exudates. The clinical diagnosis based on endoscopic findings was a benign gastric ulcer; however, biopsy was performed to distinguish it from malignant lymphoma. Histological examination of biopsy samples obtained from the base and the edge of the ulcer revealed numerous Candida. Therefore, the patient was diagnosed with Candida-infected gastric ulcer. The ulcer resolved after the administration of antiulcer drugs for 2 months. Predisposing factors for fungal infection were excluded. These observations suggest that Candida-infected gastric ulcer should be suspected in patients with a gastric submucosal tumor-like lesion with a thick, yellowish-white coated ulcer of unclear border on its summit, and this lesion should be distinguished from malignant diseases. Received: November 6, 1998 / Accepted: April 16, 1999     

Esophageal adenocarcinoma with white opaque substance observed by magnifying endoscopy with narrow band imaging

White opaque substance (WOS) is observed in the gastric neoplasia of 0‐IIa type using magnifying endoscopy with narrow band imaging (NBI‐ME). Colonic and duodenal neoplasms with WOS have also been reported. Immunohistochemical examination with adipophilin reveals WOS in gastric neoplasms as lipid droplets, and WOS is specific for neoplasm with intestinal or gastrointestinal phenotype. We herein report a case of adenocarcinoma of the esophagogastric junction with WOS. A male patient in his sixties was found by esophagogastroduodenoscopy to have an esophageal elevated lesion. NBI‐ME showed whitish deposits that looked similar to WOS in gastric neoplasms. The patient underwent endoscopic submucosal dissection and the lesion was resected in a single piece. This tumor had diffuse positivity for adipophilin and gastrointestinal phenotype.     

Endoscopic resection after endoscopic hemostasis for hemorrhagic gastric cancer

A 68 years old man was referred to our hospital with symptoms of hematemesis and melena. An emergent gastroscopy showed a gastric ulcerative lesion with an exposed vessel (Forrest IIa) protruding from its base, which was located at the posterior wall of the upper portion of the gastric body. Endoscopic hemostasis was performed with endoclips and antiulcer treatment was done. Although the ulcerative lesion was healed two months after endoscopic hemostasis, the histopathological examination of the biopsy specimens revealed well differentiated adenocarcinoma (0-IIc). The tumor could be resected en-bloc by endoscopic submucosal dissection (ESD) without any complications such as perforation or postoperative bleeding. The resected specimen showed that the resected tumor was well differentiated intramucosal adenocarcinoma (13 x 10 mm) with a clear lateral margin. There was no recurrence during 12 months follow-up after ESD treatment. Follow-up endoscopy with biopsies should be performed for accurate diagnosis of gastric ulcerative lesions and ESD after endoscopic hemostasis with endoclips was an effective method for early gastric cancer presenting with massive hemorrhage in our case.