Fujihara et al. Journal of Medical Case Reports 2012, 6:268 http://www.jmedicalcasereports.com/content/6/1/268 Page 3 of 4 Figure 4 Gastrectomy specimen showing multiple early gastric cancers in the body of the stomach. 10.2g/dL without further transfusion. The following day, upper GI endoscopy showed multiple gastric can- cer lesions (Figure 3). There was no further bleed- ing. Subsequent examination of specimens from EMR revealed well-differentiated adenocarcinoma. The lesion was removed en bloc. The resected tumor was 30mm × 25mm, and histological examination revealed well- differentiated tubular adenocarcinoma limited to the submucosal layer. Biopsy specimens that were obtained from other lesions revealed well-differentiated adenocar- cinoma and signet-ring cell carcinoma. There was no evidence of hepatic metastasis, lung metastasis, or peri- toneal metastasis based on the CT and positron emission tomography findings. Total gastrectomy with a radical lymph node dissection was performed with a preopera- tive diagnosis of multiple gastric cancers. This patient had eight synchronous gastric cancer lesions (Figure 4). Histological examination showed various types of cancer (Figure 5a-c): well-differentiated, moderately-differentiated, and poorly-differentiated adenocarcinoma and signet-ring cell carcinoma that had developed independently in the mucosal and submucosal layers of the resected specimen. Our patient’s symptoms resolved after surgery, and she remained asymptomatic at the follow-up one-and-a-half years later. Discussion This is a report of gastric cancer associated with eight gastric cancer lesions, proven on histopathology, in which hemostasis was obtained by endoscopic treatment. Malignant tumors of the stomach and duodenum fre- quently cause chronic GI blood loss and anemia, but acute upper GI bleeding is uncommon (2% to 4% of episodes of acute upper GI bleeding). The mortality rate for patients with gastric carcinoma presenting with acute hemorrhage is extremely high [3-5]. The reported median survival for patients with acute tumor bleeding ranges from 39 days to 12 weeks [3,4]. Endoscopic hemostasis for severe upper GI bleeding due to tumors, such as GI stromal tumors and malignant lymphoma, is temporarily effective [1]. APC is particu- larly useful for identification of the vessels responsible for the bleeding [6,7]. However, permanent hemostasis is Figure 5 Histological examination showed various types of cancer: well-differentiated, moderately-differentiated, and poorly- differentiated adenocarcinoma and signet-ring cell carcinoma that had developed independently in the mucosal and submucosal layers of the resected specimen. (a) No. 1 revealed a well-differentiated adenocarcinoma with a moderately-differentiated adenocarcinoma. (b) No. 4 revealed a well-differentiated adenocarcinoma with a moderately-differentiated adenocarcinoma. (c) No. 5 revealed a signet-ring cell carcinoma.