Immune-inflammatory-fibrinogen score as a novel prognostic biomarker in patients with gastric cancer undergoing radical gastrectomy: a multicenter study

World Journal of Surgical Oncology https://doi.org/10.1186/s12957-026-04439-8 Article in Press Immune-inflammatory-fibrinogen score as a novel prognostic biomarker in patients with gastric cancer undergoing radical gastrectomy: a multicenter study Wei Zhao, Qing Zhong, Bao-Long Li, Cai-Ming Weng, Hao-Xiang Zhang, Gang Wang, Zhi-Quan Zhang, Ying-Xin Wu, Dong Wu, Jun-Yu Chen, Qi-Yue Chen, Chao-Hui Zheng, Chang-Ming Huang & Jian-Wei Xie Received: 7 February 2026 Accepted: 25 May 2026 Cite this article as: Zhao W., Zhong Q., Li B. et al. Immune-inflammatoryfibrinogen score as a novel prognostic biomarker in patients with gastric cancer undergoing radical gastrectomy: a multicenter study. World J Surg Onc (2026). https://doi.org/10.1186/ s12957-026-04439-8 A E R P S S We are providing an unedited version of this manuscript to give early access to its findings. Before final publication, the manuscript will undergo further editing. 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To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. ACCEPTED ARTICLEMANUSCRIPT IN PRESS Immune-inflammatory-fibrinogen score as a novel prognostic biomarker in patients with gastric cancer undergoing radical gastrectomy: a multicenter study Wei Zhao, MD1,2,3#,Qing Zhong, Ph.D.1,2#,Bao-Long Li,MD1,4, Cai-Ming Weng,MD1,2, Hao-Xiang Zhang, MD1,2,Gang Wang, MD1,4,Zhi-Quan Zhang, MD1,2,Ying-Xin Wu, MD1,5,Dong Wu, MD1,2,Jun-Yu Chen, MD1,2,Qi-Yue Chen, Ph.D.1,2, Chao-Hui Zheng, Ph.D.1,2, Chang-Ming Huang, MD 1Department 1,2, Jian-Wei Xie, Ph.D.1,2* of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; 2Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China; 3Department University, yinchuan, China; 4Department of General Surgery, The Fifth Affiliated Hospital, Southern Medical University, Guangzhou, China.; 5Section S S E R P of Gastrointestinal Surgery, General Hospital of Ningxia Medical E L C I T R A IN for Gastrointestinal Surgery, Department of General Surgery, The Third People's Hospital of Chengdu, Chengdu, China. #Wei Zhao and Qing Zhong contributed equally to this work and should be considered shared first authors. *Corresponding to Jian-Wei Xie, E-mail: ; Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xin-quan Road, Fuzhou, 350001, Fujian Province, China. Abstract Background: Gastric cancer (GC) progression involves changes in immune responses, inflammation, and coagulation. The prognostic value of related biomarkers remains unclear. This study aimed to develop a novel immune-inflammation-fibrinogen score (FSL score) to predict outcomes in ACCEPTED ARTICLEMANUSCRIPT IN PRESS GC patients after radical gastrectomy. Methods: Clinicopathological data from 401 GC patients enrolled in a randomized controlled trial (2015–2016; ClinicalTrials.gov: NCT02327481) were retrospectively analyzed as the training cohort, with 173 patients included for external validation. Cox regression was used to construct the FSL score based on preoperative hematological markers and to evaluate its association with overall survival (OS) and recurrence-free survival (RFS). A nomogram incorporating the FSL score and clinicopathological factors was developed and evaluated using the C-index, time-dependent AUC, calibration curves, AIC, BIC, and decision curve analysis (DCA), and compared with the AJCC 8th TNM staging system. Results: Patients with high FSL scores had significantly better 3-year OS S S E R P (training cohort: 87.4% vs. 71.3%, p = 0.001; validation cohort: 68.4% vs. 42.6%, p = 0.009) and RFS (training cohort: 81.0% vs. 67.6%, p = 0.001; validation cohort: 72.4% vs. 54.9%, p IN = 0.025). The FSL score independently predicted OS and RFS (all p < 0.05). A nomogram E L C I T R A integrating the FSL score, preoperative CEA level, pT stage, pN stage, and postoperative chemotherapy outperformed the TNM system for OS (C-index: 0.806 vs. 0.757; AIC: 1378.25 vs. 1395.73; BIC: 1390.49 vs. 1394.10) and RFS (C-index: 0.803 vs. 0.763; AIC: 1310.10 vs. 1319.08; BIC: 1320.11 vs. 1322.26), with good discrimination, calibration, and clinical utility confirmed by DCA and external validation. Conclusions: The FSL score is a promising prognostic biomarker for GC patients undergoing radical gastrectomy. The proposed nomogram enables accurate and individualized survival prediction. Keywords: Gastric cancer; FSL score; radical surgery; prognosis ； Nomogram Introduction Gastric cancer (GC) represents a major global public health burden[1], ranking among the top five cancers for both incidence and cancer-related ACCEPTED ARTICLEMANUSCRIPT IN PRESS mortality worldwide[2]. More than 1 million new cases and approximately 769,000 deaths occur annually[1, 3]. Despite advances in radical surgery and adjuvant therapy, clinical outcomes after radical resection remain highly heterogeneous[4-7]. This variability highlights the urgent need for accurate and individualized prognostic tools to support clinical decision-making. As a biologically complex and heterogeneous malignancy, GC prognosis is determined by tumor characteristics, host immune status, and systemic factors, including inflammation and coagulation[8-11]. The American Joint Committee on Cancer (AJCC) TNM staging system remains the standard for prognostic evaluation. However, it is largely anatomy based and does not account for the influence of systemic biological processes such as inflammation and coagulation[12, 13]. S S E R P Recently, inflammation- and coagulation-related biomarkers, including the neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and fibrinogen (FIB), IN have demonstrated prognostic val (...truncated)