Background: Relevant serum tumor markers have been indicated to be associated with peritoneal dissemination (PD) of gastric cancer (GC). Fibrinogen has been shown to play an important role in the systemic inflammatory response (SIR) and in tumor progression. However, the clinical significance of the fibrinogen-to-lymphocyte ratio (FLR) in GC with PD has not been studied. Methods: The clinical data of 391 patients with GC were collected, including 86 cases of PD. Then, 1:3 matching was performed by propensity score matching (PSM), and the clinical data of the matched 344 patients were analyzed by univariate and multivariate conditional logistic regression. Classification tree analysis was used to obtain the decision rules and a random forest algorithm to extract the important risk factors of PD in GC. A nomogram model for risk assessment of PD in GC was established by using the rms package of R software. Results: Univariate analysis showed that the factors related to PD in GC were: carbohydrate antigen (CA) 125 (P < 0.0001), CA19-9 (P < 0.0001), CA72-4 (P < 0.0001), FLR (P < 0.0001), neutrophil-to-lymphocyte ratio (NLR) (P < 0.0001), albumin-to- lymphocyte ratio (ALR) (P < 0.0001), platelet-to-lymphocyte ratio (PLR) (P = 0.013), and carcinoembryonic antigen (CEA) (P = 0.031). Conditional logistic regression found that CA125 (OR: 1.046; P < 0.0001), CA19-9 (OR: 1.002; P < 0.0001), and FLR (OR: 1.266; P = 0.024) were independent risk factors for GC with PD. The accuracy, sensitivity, specificity, positive predictive value and negative predictive value of the decision rules for detecting PD of GC were 89.5, 77.4, 94.0, 82.8, and 91.8%, respectively. According to the important variables identified by the classification tree and random forest algorithm, the risk assessment model of PD in GC was established. The accuracy, sensitivity, and specificity of the model were 91, 89.5, and 79.5%, respectively. Conclusion: CA125 > 17.3 U/ml, CA19-9 > 27.315 U/ml, and FLR > 2.555 were the risk factors for GC with PD. The decision rules and nomogram model constructed by CA125, CA19-9, CA72-4, and FLR can correctly predict the risk of PD in GC.

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