Objective To habitually explore the clinical characteristics of gastric cancer combined with myeloid necrosis and to improve the understanding of this disease. Methods The clinical data of three patients with gastric cancer combined with bone marrow necrosis admitted to our hospital from 2008-2009 were reported, and the literature of this disease was reviewed. Results The patients with this disease had complex clinical manifestations, all had severe anemia and bleeding tendency, and all of the gastric cancer pathologies were highly malignant tissue types, most of them died within 1 month, reasonable chemotherapy could significantly improve the prognosis, and surgical treatment was not beneficial. Conclusion The clinical manifestations of bone marrow necrosis caused by gastric cancer are not very typical. Any gastric cancer patient with fever, bone pain, severe anemia and bleeding tendency should consider the possibility of bone marrow necrosis, and chemotherapy for gastric cancer may help to improve the prognosis, while surgery should be performed with caution. Gastric cancer combined with bone marrow necrosis is very rare clinically, with no more than 40 cases reported worldwide in the past 20 years, and the prognosis is extremely poor. The initial clinical manifestations are not very typical, so it is easy to be misdiagnosed and missed, thus delaying the treatment. In this paper, we report three cases of gastric cancer combined with myeloid necrosis admitted to our hospital from 2008-2009, and analyze them together with 18 cases reported in domestic and international literature to discuss their clinical characteristics and diagnosis and treatment strategies. All three cases were diagnosed by histopathological examination and bone marrow aspiration smear, and all three cases showed abdominal pain, black stool and anemia; two cases showed fever, bone pain, yellow sclera and sternal pressure; one case showed petechiae on the extremities and intestinal obstruction. Laboratory tests mainly showed decreased hemoglobin, platelets and prolonged prothrombin time. Bone marrow aspiration showed a yellowish-brown or brownish-mucous appearance, and smears showed typical features of bone marrow necrosis. Treatment: In one case, an emergency laparotomy was performed on the second day after admission due to peritonitis, and an intraoperative occupying lesion in the gastric sinus and multiple enlarged lymph nodes in the abdominal cavity were seen. One case was admitted to the hospital and given symptomatic treatment such as blood transfusion, hemostasis, anti-infection, granulocyte colony-stimulating factor and adrenocorticotropic hormone. The disease had improved for a time and died of cachexia after 3 months. In the other case, only anti-infection, blood transfusion, hemostasis and other active symptomatic treatment were given, but the patient did not improve and died 10 days after admission. Literature review 1. Literature search: The authors searched PubMed, MEDLINE, Chinese Biomedical Literature Database and Chinese Science and Technology Journal Full Text Database and collected 29 cases of gastric cancer combined with bone marrow necrosis from 1981 to 2009, excluding those with incomplete clinical information and repeated reports, 18 valid cases, plus these 3 patients reported by us, a total of 21 cases were included in the summary analysis. Among them, 6 cases were male and 15 cases were female, with a male-to-female ratio of 1.0:2.5; ages ranged from 22 to 68 (mean 43.8) years. 2. Diagnosis: (1) Symptoms: all patients showed varying degrees of anemia, 12 cases of fever, 10 cases of black stool, 12 cases of bone and joint pain, 8 cases of abdominal distension and decreased appetite, 6 cases of abdominal pain, 7 cases of palpitation and shortness of breath, 5 cases of weakness, and 1 case of cessation of anal venting and defecation. (2) Physical signs: sternal pressure pain in 8 cases, skin petechiae in 7 cases, superficial lymph node enlargement in 6 cases, abdominal pressure pain in 6 cases, and yellow sclera staining of the skin in 3 cases. (3) Laboratory tests: all patients had varying degrees of decreased hemoglobin and platelets, 15 cases of elevated leukocytes, 17 cases of elevated alkaline phosphatase (ALP), 19 cases of prolonged coagulation time, 15 cases of positive fecal occult blood, 8 cases of abnormal liver function, and 7 cases of abnormal renal function. (4) Diagnosis: 6 cases of gastric indolent cell carcinoma, 3 cases of mucinous adenocarcinoma, 3 cases of gastric hypofractionated adenocarcinoma, and 9 other patients with unknown histological type (not indicated in the literature); bone marrow necrosis were all diagnosed by histopathological examination of bone marrow aspiration. Treatment and prognosis: 9 patients were treated with symptomatic support such as anti-infection, hemostasis, and transfusion of red blood cells and platelets, which had little effect and all died within 20 d after treatment or were discharged automatically when their condition worsened; 4 cases were treated with dexamethasone and plasma exchange on the basis of symptomatic treatment such as blood transfusion and anti-infection, which had some effect, and 1 case survived for 58 d, and the prognosis of the other 2 cases was unknown; 4 cases were treated with dissection. Three of them died within 14 days after postoperative exacerbation, while the other one survived for 92 d after postoperative treatment with colony-stimulating factor and active symptomatic treatment; three cases were treated with chemotherapy for gastric cancer, two survived for 3 months, and one survived for 9 months after follow-up. Gastric cancer combined with bone marrow necrosis mostly occurs in young people and is more common in women, and gastric cancer is often considered as the primary cause of bone marrow necrosis. The clinical manifestations are complicated, mainly the symptoms of gastric cancer itself and myeloid necrosis, which are vague pain and discomfort in the upper abdomen, loss of appetite, abdominal distention, black stool, emaciation, anemia, fever, bone pain, skin petechiae and gum bleeding. Anemia is the most common symptom of the disease, often manifested as pernicious anemia. About 70% of the cases have fever, with body temperature ranging from 37.5 to 40.0 ℃, and the fever is indolent or flaccid. Bone pain is usually multi-site, persistent and severe, mainly occurring in the active parts of hematopoietic tissues, such as chest, low back and spine. Among the manifestations of gastric cancer, abdominal pain and bloating are the primary symptoms. Black stool is more common in this disease, but often neglected by patients. The disease is extremely rare clinically and difficult to diagnose. Any patient with gastric cancer who presents with clinical manifestations such as fever, pernicious anemia, bleeding and bone pain that are difficult to explain should be highly suspected of the possibility of the disease. It is worth noting that elevated alkaline phosphatase often indicates bone marrow necrosis. Therefore, some scholars believe that it is necessary to perform bone marrow aspiration smear examination for any patient with elevated ALP in gastric cancer. When bone marrow aspiration is performed, multiple sites should be taken to determine the extent and degree of bone marrow necrosis to avoid missed diagnosis. Since the disease is very rare and there is a lack of sufficient clinical and basic research, there is no definite treatment method. The general treatment principle is that the treatment of gastric cancer should take into full consideration the characteristics of bone marrow necrosis itself and provide active symptomatic support treatment such as anti-infection, blood transfusion and hemostasis. However, because the primary cause of myelonecrosis is a highly malignant gastric cancer, the prognosis of this disease is extremely poor, and most patients die within 3 weeks after diagnosis. The prognosis of our patients was similar to that reported in the literature. It is noteworthy that all three patients given chemotherapy according to the gastric cancer chemotherapy regimen survived for more than 3 months, and one of them was still alive at 9 months of follow-up. It is suggested that timely chemotherapy for gastric cancer may be fundamental to improve the prognosis of this disease, but most of the patients were critically ill at the time of admission, making it difficult to administer chemotherapy. In the four patients who underwent surgery, radical resection was difficult, and the intraoperative and postoperative wounds leaked blood severely, and three patients died in the perioperative period. Our data also showed that colony-stimulating factor and adrenocorticotropic hormone may be beneficial in prolonging the survival of patients with this disease. In conclusion, we believe that aggressive symptomatic supportive therapy and appropriate chemotherapy for gastric cancer may be effective treatment modalities for this disease, while surgical treatment should be performed with caution.