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Gastric lymphoma at high risk of perforation successfully managed with chemotherapy alone. We report the case of a previously healthy 49-year-old woman who presented with upper gastrointestinal bleeding, which was found at laparotomy to be due to high-grade B cell gastric lymphoma. CT scans showed that this was partially adherent to the spleen, with erosion of the gastric wall and suggested impending perforation. Given the risk of perforation, further surgical intervention (gastrectomy and splenectomy) was considered; however, after multidisciplinary team discussion, we chose to offer chemotherapy and careful inpatient observation instead.Our patient made a full recovery with no perforation.The message from our experience and literature review is that medical management may lead to a more favourable outcome in gastric lymphoma than surgery, despite radiological appearances suggesting impending perforation. This approach avoids the risk of the lymphoma progressing at other anatomical sites secondary to delays in giving chemotherapy. If this approach is followed, the patient must be carefully monitored.