This retrospective study suggests that the clinical outcome of localized PGL treated by chemotherapy alone is comparable to that treated by surgery combined with chemotherapy in terms of disease-free survival and overall survival, so surgery is not required. Review of the literature showed that most of the relevant studies of treatment and outcome of PGL, considered small numbers of patients and were conducted retrospectively [
9,
10]. The optimal treatment for localized PGL remains to be established. Earlier studies claimed that surgery was the first-line treatment of choice for patients with localized gastric lymphoma [
11,
12]. Advocates for primary surgery included that patients who underwent surgery had a better survival than those who did not, and surgery might reduce the risk of bleeding or perforation during chemotherapy or radiotherapy. However because the success of surgical management of PGL depends on tumor size, the depth of its penetration into gastric tissue, and the involvement of regional lymph nodes [
13‐
15] some investigators began using chemotherapy, mostly CHOP and its related regimens, to control the tumors and prevent postoperative morbidity gastrectomy [
9,
16,
17]. Recently the roles of stomach-conserving therapies for localized PGL have been emphasized. Relatively little data, however, exist for chemotherapy as sole treatment modality in localised gastric DLBCL, which nevertheless are highly promising and suggest that combination therapy might over treat a substantial proportion of patients [
3,
5]. Maor and al showed that the 6-year overall survival of patients treated with chemotherapy alone was 76% [
17]. However, for bulky tumors, the advantage of chemotherapy is overshadowed by the potential for tumor bleeding and gastric perforation. Most studies have revealed a rather low incidence of severe haemorrhage or perforation, accounting for 2.1% and 1.7%, respectively, of those individuals treated with chemotherapy alone, and 2.2% and 0.9%, respectively, of surgically-treated individuals [
17,
18]. Such evidence suggests that the role of surgery in the treatment of PGL may be less important than previously considered. In our study, gastric perforation and gastric bleeding developed respectively in 3 patients and 2 patients receiving primary chemotherapy and thus this remains a real and noteworthy complication. To avoid such severe complications, we recommend re-evaluating patients by endoscopy after two cycles of chemotherapy. At the same time, patients should be warned that complications such as gastric perforation and bleeding are possible, and awareness programs involving comprehensive education should be part of the treatment process [
19]. Our study has provided good evidence in support of chemotherapy alone. The best management of PGL has yet not been established and the choice of treatment modality is mainly dependent on the expertise of the primary responsible specialists. Oncologists preferred systemic chemotherapy alone and reserved surgery as salvage treatment, while surgeons preferred curative resection followed by adjuvant chemotherapy [
20]. Such variation in patient selection has made comparison among different studies difficult. Prospective studies are needed to evaluate each strategy in terms of both survival and treatment-related complications. Our data suggest that systemic chemotherapy alone may be a reasonable alternative treatment for stage I/II large-cell lymphoma of the stomach. We may presume, however, that organ function is better preserved by chemotherapy alone than surgery. Resection of the primary tumor before systemic chemotherapy does not appear to improve the cure rate of this group of patients and could be reserved for those with severe complication (severe bleeding or perforation) after chemotherapy but this result must be confirmed in prospective randomized clinical trial including monoclonal antibody.