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We report on a 51-year-old female patient with familial adenomatous polyposis (FAP) that developed into advanced gastric cancer after long-term observation without any treatment (>12 years). We observed gastric carcinogenesis using immunohistochemistry. The patient had a FAP pedigree, and onset of FAP is reported in 11 members of her family. During clinic visits, a total of 12 endoscopies of the large bowel were carried out and tubular adenoma of group 2–3 was seen during all examinations. In a recent detailed examination of the upper gastrointestinal tract, Borr type III gastric cancer was found, with many hepatic metastasis lesions and many polyps in the fundic gland (fig 1A,B).