Beyond Traditional Prognostic Scores: Associations of Organ Dysfunction and Metastatic Malignancy with Mortality in Fournier’s Gangrene

Background: Fournier's gangrene (FG) is a rare, rapidly progressive necrotizing soft-tissue infection associated with high mortality. Early identification of high-risk patients remains essential, but the comparative performance of prognostic scores and the impact of Sepsis-3 classification and malignancy status remain incompletely de-fined. Methods: We conducted a retrospective observational cohort study including 21 con-secutive adults with surgically confirmed FG treated at a tertiary referral center be-tween 2019 and 2025. Clinical characteristics, Sepsis-3 classification, malignancy sta-tus, and admission severity scores (FGSI, SFGSI, LRINEC, and NLR) were analyzed. Prognostic performance was assessed using ROC analysis, while associations with in-hospital mortality were evaluated using Fisher's exact test and Firth's bias-reduced logistic regression. Results: In-hospital mortality was 19.0% (4/21). FGSI showed the highest predictive accuracy (AUC 0.934), followed by SFGSI (AUC 0.919), while LRINEC performed well (AUC 0.860) and NLR showed limited discrimination (AUC 0.574). Confirmed Sepsis-3-defined sepsis occurred in 33.3% of patients and was strongly associated with mortality (57.1% vs. 0%; p = 0.006). Although 76.2% presented with confirmed or probable sepsis, all deaths occurred exclusively in patients with or-gan dysfunction. Metastatic malignancy was observed only in non-survivors and was significantly associated with mortality (100.0% vs. 10.5%; p = 0.029). No severity score correlated with hospital length of stay. Conclusions: FGSI and SFGSI demonstrated excellent prognostic performance. Sepsis-3-defined organ dysfunction and metastatic malignancy emerged as strong predictors of mortality, suggesting that their integra-tion into future prognostic models may improve early risk stratification and individu-alized management in patients with FG.