Chemotherapy for primary gastric lymphoma: does in-patient observation prevent complications?

Primary gastric lymphoma (PGL) is the most common site of extra-nodal non-Hodgkin's lymphoma (NHL). In recent years there has been a move away from a surgical approach to primary chemotherapy with or without radiotherapy. Data support this approach, with overall survival rates equivalent or superior to surgery. Concerns have been raised over the incidence of acute chemotherapy complications, primarily gastrointestinal (GI) haemorrhage and perforation. As a result, several units, including our own, have routinely admitted all patients for observation during the commencement of therapy. We conducted an audit to elucidate the incidence and timing of such complications.

We used our prospectively recorded lymphoma database to identify all patients with aggressive PGL treated with primary chemotherapy. We examined individual patient notes for the incidence of gastric perforation and GI haemorrhage, defined as a fall in haemoglobin of least 2 g/dl, or the occurrence of haematemesis or malaena.

We identified 29 patients with aggressive PGL who received primary systemic chemotherapy. Of these, only two had acute complications, one with GI bleed and the other with perforation. Both events occurred after discharge following our standard inpatient admission period of 5 days (day 13 and day 17).

In this study, the rate of acute chemotherapy-related complications is low (6.9%). This is consistent with most published series, in which the incidence seems to be around 5% or less. Both acute complications in this series occurred after the patients had been discharged following a routine admission period of 5 days for observation. Although rarely documented, other series suggest that these events also occur late after the initiation of chemotherapy. This work suggests that routine admission for the initiation of chemotherapy for PGL is not necessary and should be at the discretion of the treating physician. All patients should receive comprehensive education about the risks and clinical signs of gastric perforation and bleed. This change in policy has obvious implications for healthcare resources.