We aimed to investigate the impact of muscle atrophy and the neutrophil-to-lymphocyte ratio (NLR), a sub-clinical biomarker of inflammation and nutrition, on the prognosis of patients with unresectable advanced gastric cancer. We retrospectively enrolled 109 patients with stage IV gastric cancer (median age 69 years; female/male 22%/78%; median observational period 261 days). Independent factors and profiles for overall survival (OS) were determined by Cox regression analysis and decision-tree analysis, respectively. OS was calculated using the Kaplan–Meier method. The prevalence of muscle atrophy was 82.6% and the median NLR was 3.15. In Cox regression analysis, none of factors were identified as an independent factor for survival. The decision-tree analysis revealed that the most favorable prognostic profile was non-muscle atrophy (OS rate 36.8%). The most unfavorable prognostic profile was the combination of muscle atrophy and high NLR (OS rate 19.6%). The OS rate was significantly lower in patients with muscle atrophy and high NLR than in patients with non-muscle atrophy (1-year survival rate 28.5% vs. 54.7%; log-rank test p = 0.0014). In conclusion, “muscle atrophy and high NLR” was a prognostic profile for patients with stage IV gastric cancer. Thus, the assessment of muscle mass, subclinical inflammation, and malnutrition may be important for the management of patients with stage IV gastric cancer.

Abstract. Peritoneovenous shunt is normally used for the treatment of refractory ascites. However, its efficacy in treating tolvaptan-resistant refractory ascites has not been reported thus far. In addition, the impact of peritoneovenous shunt on the prognosis of cirrhotic patients remains controversial. In the present report, a case of tolvaptan-resistant refractory ascites associated with liver cirrhosis and portal vein thrombosis is described. The male patient was diagnosed with hepatitis C virus-related liver cirrhosis at the age of 51 years. At the age of 56 years, the patient developed portal vein thrombosis, resulting in the development of refractory ascites. Since the ascites was resistant to treatment with a low-sodium diet and diuretics such as tolvaptan, a peritoneovenous shunt was implanted upon obtaining consent. The shunt immediately increased the urine volume, and the ascites was markedly decreased. The patient's body weight decreased from 62.7 to 57.1 kg in 2 days, and his ascites symptom inventory-7 score decreased from 23 to 0 points in 31 days. Although the patient succumbed to sepsis on day 486 following the shunt implant, his activities of daily living were preserved until 8 days prior to mortality. Thus, the present case supports the efficacy of peritoneovenous shunt for the treatment of tolvaptan-resistant refractory ascites associated with liver cirrhosis and portal vein thrombosis. Furthermore, the present case suggests that peritoneovenous shunt may prolong the survival of cirrhotic patents with refractory ascites. IntroductionAscites that does not resolve with standard medical treatment such a low-sodium diet and diuretics is known as refractory ascites, and is frequently associated with the development of hepatorenal syndrome, spontaneous bacterial peritonitis and dilutional hyponatremia (1). Refractory ascites also causes a loss of appetite and muscle wasting, and impairs the activities of daily living (ADL) (1). Thus, refractory ascites is a life-threatening complication that lowers the quality of life of cirrhotic patients, and is an independent predictor of short survival (1,2).One of the main reasons for cirrhosis-related water retention is a reduced ability of the kidneys to excrete electrolyte-free water, due to an increase in the levels of arginine vasopressin (3). Arginine vasopressin receptor antagonists, a novel class of diuretics, have been recently approved for the treatment of cirrhosis-related fluid retention in Japan (3,4). These diuretics antagonize vasopressin V2 receptors, resulting in the inhibition of electrolyte-free water reabsorption and an increase in electrolyte-free water excretion (5). Tolvaptan, a vasopressin V2 receptor antagonist, improves hepatic edema and reduces ascites in cirrhotic patients (6,7). However, tolvaptan may not always be effective for treating refractory ascites, since there are various mechanisms involved in the development of this condition (1,8).Peritoneovenous shunt was designed to transport ascites from the peritoneal cavity back in...