Recurrence scoring system predicting early recurrence for patients with pancreatic ductal adenocarcinoma undergoing pancreatectomy and portomesenteric vein resection.

Early recurrence (ER) is associated with dismal outcomes in patients undergoing radical resection for pancreatic ductal adenocarcinoma (PDAC). Approaches for predicting ER will help clinicians in implementing individualized adjuvant therapies. Postoperative serum tumor markers (STMs) are indicators of tumor progression and may improve current systems for predicting ER. To establish an improved nomogram based on postoperative STMs to predict ER in PDAC. We retrospectively enrolled 282 patients who underwent radical resection for PDAC at our institute between 2019 and 2021. Univariate and multivariate Cox regression analyses of variables with or without postoperative STMs, were performed to identify independent risk factors for ER. A nomogram was constructed based on the independent postoperative STMs. Receiver operating characteristic curve analysis was used to evaluate the area under the curve (AUC) of the nomogram. Survival analysis was performed using Kaplan-Meier survival plot and log-rank test. Postoperative carbohydrate antigen 19-9 and carcinoembryonic antigen levels, preoperative carbohydrate antigen 125 levels, perineural invasion, and pTNM stage III were independent risk factors for ER in PDAC. The postoperative STMs-based nomogram (AUC: 0.774, 95%CI: 0.713-0.835) had superior accuracy in predicting ER compared with the nomogram without postoperative STMs (AUC: 0.688, 95%CI: 0.625-0.750) (P = 0.016). Patients with a recurrence nomogram score (RNS) > 1.56 were at high risk for ER, and had significantly poorer recurrence-free survival [median: 3.08 months, interquartile range (IQR): 1.80-8.15] than those with RNS ≤ 1.56 (14.00 months, IQR: 6.67-24.80), P < 0.001). The postoperative STMs-based nomogram improves the predictive accuracy of ER in PDAC, stratifies the risk of ER, and identifies patients at high risk of ER for tailored adjuvant therapies.

BackgroundPancreatic ductal adenocarcinoma (PDAC) is one of the most lethal cancers, and surgical resection is the only potentially curative approach. However, the rate of recurrence remains high, particularly within the first 6 months, and is associated with a poor prognosis. The present study evaluated the clinical characteristics and risk factors for early recurrence in pancreatic ductal adenocarcinoma (PDAC) patients who underwent curative resection, regardless of the use of neoadjuvant chemotherapy, to identify predictive factors associated with early recurrence and poor outcomes as well as to determine the optimal treatment strategy for patients at high risk of early recurrence after surgical resection.MethodsPatients who underwent pancreatic resection for PDAC at our institution from 2013 to 2021 were included in this study. We investigated the clinicopathological features of patients in groups: those with recurrence within 6 months, recurrence between 6 and 12 months, and recurrence beyond 12 months or no recurrence. A logistic regression analysis identified covariates associated with early recurrence at 6 and 12 months.ResultsThe study included 403 patients with a median follow-up of 25.7 months. Recurrence was observed in 279 patients, with 14.6% recurring within 6 months, 23.3% within 6–12 months, and 62% after 12 months or not at all. The preoperative CA19-9 level, modified Glasgow prognostic score (mGPS), and positive peritoneal cytology were significant risk factors for early recurrence within 6 months, while positive peritoneal cytology, lymph node metastasis, and the absence of adjuvant chemotherapy were significant risk factors for recurrence within 12 months. For patients who received preoperative chemotherapy or chemoradiotherapy, the preoperative CA19-9 level, mGPS, and positive peritoneal cytology were significant independent risk factors for early recurrence within 6 months, while positive peritoneal cytology, lymph node metastasis, and the absence of adjuvant chemotherapy were significant independent risk factors for recurrence within 12 months. The study concluded that the overall survival after surgical resection for potentially resectable PDAC worsened according to the number of risk factors present in the patient.ConclusionsWe clarified that preoperative CA19-9, positive peritoneal cytology, and the lack of adjuvant chemotherapy were consistent predictors for early recurrence within 6 and 12 months. In addition, an increased number of risk factors affecting the patient was associated with a poorer overall survival after potentially curable resection. Calculating the number of risk factors for early recurrence may be an essential predictive factor when considering treatment strategies.

The role of carcinoembryonic antigen (CEA) in pancreatic cancer remains poorly understood. Therefore, this study aimed to determine whether CEA is complementary to carbohydrate antigen 19-9 (CA19-9) in prognosis prediction after pancreatic cancer curative resection. We retrospectively reviewed records of 144 stage II curatively resected pancreatic cancer patients with preoperative and postoperative CEA and CA19-9 levels. Patients with normal preoperative CA19-9 were excluded. R0 resection margin, adjuvant treatment, and absence of angiolymphatic invasion were associated with better overall survival. There was no significant difference in median survival according to preoperative CEA levels. However, patients with normal postoperative CA19-9 (59.8 vs.16.2 months, P < 0.001) and CEA (29.4 vs. 9.3 months, P = 0.001) levels had longer overall survival than those with elevated levels. Among 76 patients with high postoperative CA19-9 levels, a better prognosis was observed in those with normal postoperative CEA levels than in those with elevated levels (19.1 vs. 9.3 months, P = 0.004). Postoperative CEA and CA19-9 levels are valuable prognostic markers in resected pancreatic cancer. Normal postoperative CEA levels indicate longer survival, even in patients with elevated postoperative CA19-9.

Comparison of the prognostic impact of pre- and post-operative CA19-9, SPan-1, and DUPAN-II levels in patients with pancreatic carcinoma

BACKGROUNDPredicting early recurrence (ER), (≤ 12 months) after pancreatic ductal adenocarcinoma (PDAC) resection remains challenging. Preoperative biomarkers such as carbohydrate antigen 19-9 (CA19-9) and computed tomography (CT) lack optimal specificity and reproducibility. Extracellular volume (ECV), measured on equilibrium-phase CT to quantify stromal fibrosis, correlates with PDAC progression but its utility for ER prediction is unknown. This study evaluates preoperative CT-ECV as a novel biomarker to predict ER following curative-intent PDAC resection.AIMTo investigate the utility of CT-ECV for preoperative prediction of ER in PDAC patients after R0 resection.METHODSThis retrospective study included 93 PDAC patients undergoing R0 resection and preoperative pancreatic CT from January 2020 to November 2023. Clinical and CT features were analyzed. ECV was calculated using unenhanced and equilibrium-phase CT. Univariable and multivariable Cox regression identified ER predictors, followed by receiver operating characteristic analysis. Recurrence-free survival (RFS) was assessed by the Kaplan-Meier method.RESULTSMultivariable analysis identified elevated CT-ECV [hazard ratio (HR) = 1.05; 95% confidence interval (CI): 1.02-1.09; P = 0.003], high preoperative CA19-9 (HR = 1.00; 95%CI: 1.00-1.00; P = 0.002), and poor tumor grade (HR = 2.51; 95%CI: 1.20-5.22; P = 0.014) as independent ER predictors. CT-ECV demonstrated comparable predictive accuracy to tumor grade [areas under the curve (AUC): 0.736 vs 0.650; P = 0.202]. Combining CT-ECV and CA19-9 achieved a higher AUC than tumor grade alone (0.759 vs 0.650; P < 0.05). Kaplan-Meier analysis revealed significantly shorter RFS in patients with low CT-ECV (≤ 35.37%), elevated CA19-9 (> 55 U/mL), or poorly differentiated tumors compared to those with high CT-ECV (> 35.37%), low CA19-9 (≤ 55 U/mL), or moderately/well-differentiated tumors.CONCLUSIONCT-derived ECV is a promising non-invasive biomarker for preoperative ER prediction in PDAC. Combined with CA19-9, it outperforms tumor grade in stratifying recurrence risk, offering a clinically actionable tool for optimizing postoperative management.

Background: Although women diagnosed with early-stage estrogen receptor (ER)-positive breast cancer generally have a favorable prognosis, they face a lingering risk of late recurrence that can occur years to decades after diagnosis. Relatively little is known about the demographic, lifestyle, or clinical factors associated with the risk of late recurrence, or whether the associations differ between early vs. late recurrence. Methods: We performed a comprehensive analysis of factors related to early vs. late recurrence in early-stage ER-positive breast cancer in the Pathways Study, an established prospective cohort of women diagnosed with invasive breast cancer at Kaiser Permanente Northern California (KPNC) between 2006 and 2013. Recurrences were identified through monthly searches of the KPNC Cancer Registry, follow-up interviews with participants, and confirmation with electronic medical records. For this analysis, 2,473 women with stage I-IIB, ER-positive breast cancer were included, with ascertainment of recurrence and death through December 31, 2021. Univariate analysis and multivariable Cox regression models were used to examine the factors associated with early (&amp;lt; 5 years since diagnosis) and late (≥ 5 years since diagnosis) recurrence. Results: The median age of diagnosis was 57 (± 10) years, with 35% diagnosed before menopause. While 64% of patients self-reported as White, 16% identified as Asian, 6% Black, 12% Hispanic, and 2% other ethnicity. After a median 13.3 (range: 0.6-16.8) years of follow up, a total of 341 (13.8%) recurrences occurred, with 158 before and 181 at or after 5 years from diagnosis. Approximately a third of recurrences were local or regional and the other two thirds were distant. In univariate analysis, increasing stage and tumor grade were associated with higher risk of both early and late recurrence (p&amp;lt; 0.05). Progesterone receptor (PR) negativity was associated with only early (hazard ratio [HR]=1.49, 95% confidence interval [CI] 1.06-2.09) but not late recurrence (HR=0.90, 95% CI 0.63-1.28). In unadjusted models, receiving lumpectomy (vs. mastectomy), chemotherapy, radiation therapy, or endocrine therapy were associated with lower risk of both early and late recurrence. Among the demographic and lifestyle factors examined, postmenopausal status at diagnosis was associated with lower risk of early (HR=0.69, 95% CI 0.51-0.96) but not late recurrence (HR=1.00, 95% CI 0.73-1.36). No association was found with body mass index, socioeconomic measures (education, income, employment, marital status), smoking, alcohol intake, or physical activity assessed at the time close to diagnosis. Notably, minoritized racial/ethnic groups all had higher risk of early recurrence than White women (Asian: HR=1.76, 95% CI 1.16-2.66; Black: HR=2.33, 95% CI 1.38-3.93; Hispanic: HR=1.80, 95% CI 1.15-2.82), but no association was found with late recurrence (Asian: HR=0.99, 95% CI 0.65-1.51; Black: HR=0.80, 95% CI 0.41-1.58; Hispanic: HR=0.80, 95% CI 0.48-1.33). In multivariable Cox models adjusted for age, cancer stage, grade, PR status, surgery, radiation therapy, chemotherapy, and endocrine therapy, the trend of higher risk of early recurrence among minoritized racial/ethnic groups remained, although the association remained significant only in Black women (HR=1.89, 95% CI 1.08-3.31). Conclusion: Most histopathological features and cancer treatment modality had similar impact on early vs. late recurrence among women with early-stage ER-positive breast cancer, although PR negativity might be an adverse risk factor for early recurrence only. The findings of higher risk of early but not late recurrence among Asian, Black, and Hispanic relative to White women provide some novel data on the racial/ethnic disparities of prognosis for ER-positive breast cancer and may warrant further investigation. Citation Format: Alfredo Chua, Haiyang Sheng, Shipra Gandhi, Marilyn Kwan, Isaac Ergas, Janise Roh, Cecile Laurant, Thaer Khoury, Scarlett Gomez, Christine Ambrosone, Lawrence Kushi, Song Yao. Demographic, Lifestyle, and Clinical Factors Associated with Early vs. Late Recurrence among Women with Early-Stage Estrogen Receptor-Positive Breast Cancer in the Prospective Pathways Study [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-01-11.

A preoperative risk model for early recurrence after radical resection may facilitate initial treatment decisions concerning the use of neoadjuvant therapy for patients with pancreatic ductal adenocarcinoma

Early recurrence (ER) after surgical resection is an important factor that impacts the survival of patients with pancreatic ductal adenocarcinoma (PDA). We examined risk factors for ER after PDA resection. One hundred and thirteen PDA patients who underwent R0 or R1 resection were retrospectively analyzed. Thirty-four patients (30.1%) received neoadjuvant chemotherapy (NAC) for borderline resectable (BR) (n=13) or initially unresectable (n=21) disease. ER was defined as that diagnosed within 6 months after surgery. Receiver operating characteristic analysis was performed for each variable to determine the optimal cutoff value. ER occurred in 21 patients (18.6%). In univariate analysis, preoperative platelet-to-lymphocyte ratio (PLR) ≥144, carbohydrate antigen (CA) 19-9 ≥162 U/mL, and pathological tumor size ≥3 cm were significantly associated with ER. High PLR and CA19-9 were independent risk factors for ER by multivariate analysis. Area under the curve (AUC) for predicting ER from a combination of PLR and CA19-9 was 0.765 (95% confidence interval: 0.664-0.866), which increased the AUC compared to that for each risk factor alone. Patients with both risk factors had a significantly worse overall survival than those with one or no risk factors. When 24 patients with BR-PDA were considered, NAC was associated with a reduced likelihood of having risk factors and with a low ER rate. A combination of PLR and CA19-9 is a useful predictor of ER after macroscopic curative resection for PDA. NAC may reduce the risk of ER in selected patients.

Pancreatic cancer is a highly aggressive malignancy that is characterized by early metastasis, high recurrence, and therapy resistance. Early recurrence after surgery is one of the important reasons affecting the prognosis of pancreatic cancer. This study aimed to establish an accurate preoperative nomogram model for predicting early recurrence (ER) for resectable pancreatic adenocarcinoma. We retrospectively analyzed patients who underwent pancreatectomy for pancreatic ductal adenocarcinoma between January 2011 and December 2020. The training set consisted of 604 patients, while the validation set included 222 patients. Survival was estimated using Kaplan–Meier curves. The factors influencing early recurrence of resectable pancreatic cancer after surgery were investigated, then the predictive model for early recurrence was established, and subsequently the predictive model was validated based on the data of the validation group. The preoperative risk factors for ER included a Charlson age-comorbidity index ≥ 4 (odds ratio [OR]: 0.628), tumor size > 3.0 cm on computed tomography (OR: 0.628), presence of clinical symptoms (OR: 0.515), carbohydrate antigen 19-9 > 181.3 U/mL (OR 0.396), and carcinoembryonic antigen > 6.01 (OR: 0.440). The area under the curve (AUC) of the predictive model in the training group was 0.711 (95% confidence interval: 0.669–0.752), while it reached 0.730 (95% CI: 0.663–0.797) in the validation group. The predictive model may enable the prediction of the risk of postoperative ER in patients with resectable pancreatic ductal adenocarcinoma, thereby optimizing preoperative decision-making for effective treatment.

The survival of patients with pancreatic ductal adenocarcinoma (PDAC) is closely related to recurrence. It is necessary to classify the risk factors for early recurrence and to develop a tool for predicting the initial outcome after surgery. Among patients with resected resectable PDAC at Samsung Medical Center (Seoul, Korea) between January 2007 and December 2016, 631 patients were classified as the training set. Analyses identifying preoperative factors affecting early recurrence after surgery were performed. When the p-value estimated from univariable Cox’s proportional hazard regression analysis was <0.05, the variables were included in multivariable analysis and used for establishing the nomogram. The established nomogram predicted the probability of early recurrence within 12 months after surgery in resectable PDAC. One thousand bootstrap resamplings were used to validate the nomogram. The concordance index was 0.665 (95% confidence interval [CI], 0.637–0.695), and the incremental area under the curve was 0.655 (95% CI, 0.631–0.682). We developed a web-based calculator, and the nomogram is freely available at http://pdac.smchbp.org/. This is the first nomogram to predict early recurrence after surgery for resectable PDAC in the preoperative setting, providing a method to allow proceeding to treatment customized according to the risk of individual patients.

Pancreatic ductal adenocarcinoma (PDAC) is a disease with a very unfavorable prognosis. Surgical resection represents the only potentially curative treatment option, but recurrence after complete resection is almost certain. In an exploratory attempt we here aimed at identifying preoperative plasma protein biomarkers with the potential to predict early recurrence after resection of PDAC. Peripheral blood samples from 14 PDAC patients divided into three groups according to their time to tumor recurrence after curatively intended resection (early: < 6 months, medium: 6–12 months, late: > 12 months) underwent targeted proteome analysis. Proteins most strongly discriminating early and late recurrence were then examined in a number of established PDAC cell lines and their culture supernatants. Finally, PDAC organoid lines from primary tumors of patients with early and late recurrence were analyzed for confirmation and validation of results. In total, 23 proteins showed differential abundance in perioperative plasma from PDAC patients with early recurrence when compared to patients with late recurrence. Following confirmation of expression on a transcriptional and translational level in PDAC cell lines we further focused on three upregulated (MAEA, NT5E, AZU1) and two downregulated proteins (ATP6AP2, MICA). Increased expression of NT5E was confirmed in a subset of PDAC organoid cultures from tumors with early recurrence. MICA expression was heterogeneous and ATP6AP2 levels were very similar in both organoids from early and late recurrent tumors. Most strikingly, we observed high MAEA expression in all tested PDAC (n = 7) compared to a non-cancer ductal organoid line. MAEA also demonstrated potential to discriminate early recurrence from late recurrence PDAC organoids. Our study suggests that identification of plasma protein biomarkers released by tumor cells may be feasible and of value to predict the clinical course of patients. Prediction of recurrence dynamics would help to stratify up-front resectable PDAC patients for neoadjuvant chemotherapy approaches in an individualized fashion. Here, MAEA and NT5E were the most promising candidates for further evaluation.

BackgroundGiven the poor prognosis of patients with pancreatic ductal adenocarcinoma (PDAC), the accurate stratification of patients at high risk for early recurrence (ER) is an urgent need. Conventional predictors such as carbohydrate antigen 19-9 (CA19-9) and tumor diameter have suboptimal efficacy. Quantitative parameters derived from dual-energy computed tomography (DECT) and the 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG-PET/CT) serve as validated imaging biomarkers for aggressive tumor biology. This study aimed to develop an integrative nomogram that combines these imaging markers with clinicopathological factors to preoperatively predict ER in resectable PDAC.MethodsIn this single-center retrospective study, we analyzed 80 patients diagnosed with pathologically confirmed PDAC from November 2021 to July 2023. ER was defined as disease relapse within 12 months postoperatively, and patients were categorized into ER and non-early recurrence (non-ER) groups. Clinicopathological variables, including tumor markers, pathological T stage (pTs), pathological N stage (pNs), tumor location, maximum tumor diameter, perineural invasion (PNI), and lymphovascular invasion (LVI), were collected. The following preoperative DECT parameters were obtained: dual-energy index (DEI), effective atomic number (Zeff), electron density (Rho), fat fraction, iodine concentration (IC), normalized iodine concentration (NIC), and vascular involvement. The maximum standardized uptake value (SUVmax) values were extracted from the PET/CT images. Univariate and multivariate logistic regression analyses were employed to identify independent clinicopathologic and imaging predictors of early postoperative recurrence, and a nomogram was subsequently constructed. The discrimination, calibration, and clinical utility of the nomogram were evaluated via receiver operating characteristic (ROC) curves, calibration curves, and a decision curve, respectively.ResultsComparative analysis revealed significant differences between the non-ER and ER groups in terms of the maximum tumor diameter, serum CA19-9 level, pNs, LVI, portal-venous-phase (PV-NIC) value, number of veins involved, and SUVmax (all P values <0.05). Multivariate logistic regression analysis revealed lymph node metastasis [odds ratio (OR) =19.610; 95% confidence interval (CI): 1.211–340.406; P=0.032], a low PV-NIC value (OR =0.769; 95% CI: 0.617–0.945; P=0.028), a greater number of invaded vessels (OR =8.660; 95% CI: 1.083–110.245; P=0.043), and an elevated SUVmax (OR =1.739; 95% CI: 1.091–4.142; P=0.027) as independent predictors of ER in patients with PDAC. The comprehensive model achieved an area under the curve of 0.979, along with robust calibration (calibration slope =0.91).ConclusionsThe nomogram model based on DECT parameters, the PET/CT SUVmax, and clinicopathological parameters effectively predicted early postoperative recurrence in patients with PDAC.

Cell-free DNA (cfDNA) shed from tumors into the circulation offers a tool for cancer detection. Here, we evaluated the feasibility of cfDNA measurement and utility of digital PCR (dPCR)-based assays, which reduce subsampling error, for diagnosing pancreatic ductal adenocarcinoma (PDA) and surveillance of intraductal papillary mucinous neoplasm (IPMN). We collected plasma from seven institutions for cfDNA measurements. Hot-spot mutations in KRAS and GNAS in the cfDNA from patients with PDA (n = 96), undergoing surveillance for IPMN (n = 112), and normal controls (n = 76) were evaluated using pre-amplification dPCR. Upon Qubit measurement and copy number assessment of hemoglobin-subunit (HBB) and mitochondrially encoded NADH:ubiquinone oxidoreductase core subunit 1 (MT-ND1) in plasma cfDNA, HBB offered the best resolution between patients with PDA relative to healthy subjects [area under the curve (AUC) 0.862], whereas MT-ND1 revealed significant differences between IPMN and controls (AUC 0.851). DPCR utilizing pre-amplification cfDNA afforded accurate tumor-derived mutant KRAS detection in plasma in resectable PDA (AUC 0.861-0.876) and improved post-resection recurrence prediction [hazard ratio (HR) 3.179, 95% confidence interval (CI) 1.025-9.859] over that for the marker CA19-9 (HR 1.464; 95% CI 0.674-3.181). Capturing KRAS and GNAS could also provide genetic evidence in patients with IPMN-associated PDA and undergoing pancreatic surveillance. Plasma cfDNA quantification by distinct measurements is useful to predict tumor burden. Through appropriate methods, dPCR-mediated mutation detection in patients with localized PDA and IPMN likely to progress to invasive carcinoma is feasible and complements conventional biomarkers.

Objectives Pancreatic ductal adenocarcinoma (PDAC) has a high recurrence rate post-curative surgery. This study aimed to evaluate the combined predictive value of preoperative carbohydrate antigen 19-9 (CA19-9) and neutrophil-to-lymphocyte ratio (NLR) for early recurrence in resected PDAC patients. Methods This was a single-centre retrospective study involving 151 patients diagnosed with PDAC. Data on patient demographics, clinical characteristics and preoperative haematological parameters were collected. Early recurrence was defined as recurrence within the first 12 months after surgery. Univariate and multivariate logistic regression analyses were conducted to identify factors associated with early recurrence. Receiver Operating Characteristic (ROC) curves and Area Under the Curve (AUC) analyses were used to assess the diagnostic performance of CA19-9, NLR and their combination. Results Among 151 patients (median follow-up: 21 months), 32.45% (n = 49) experienced early recurrence. Multivariate logistic regression analysis revealed that preoperative CA19-9 levels and NLR were independently associated with early recurrence. ROC curve analysis demonstrated that the combination of NLR and CA19-9 had significantly better performance in predicting early recurrence compared to NLR or CA19-9 alone. Conclusion The combination of preoperative CA19-9 and NLR enhances predictive accuracy for early recurrence in PDAC, offering a useful tool for postoperative risk stratification.

To develop a score system including CT features for predicting postoperative early (≤ 1 year) recurrence-free survival (RFS) in resectable pancreatic ductal adenocarcinoma (PDAC) patients who underwent radical resection and assess its performance. This dual-center, retrospective study included patients with resectable PDAC who underwent radical resection from September 2016 to April 2023. All CT features were independently evaluated by two blinded radiologists. An early recurrence score (ERS) based on CT and clinical features, for predicting early recurrence risk, was developed by Cox regression analysis in the developing cohort, and was validated in the testing and validation cohorts and compared with AJCC TNM staging system. This study included 210 patients in the development cohort (mean age ± standard deviation, 60 ± 10 years; 129 men), 92 patients in the testing cohort (60 ± 9 years; 60 men), and 31 patients in the validation cohort (62 ± 7 years; 20 men). CA19-9 (hazard ratio [HR], 1.57; p = 0.044), perineural invasion on CT (HR, 1.83; p = 0.037), tumor necrosis (HR, 3.20; p < 0.001), and lymph nodes metastasis on CT (HR, 1.84; p = 0.004) formed the ERS. Its AUC of 0.851 and 0.901, superior to AJCC TNM staging (AUC of 0.630 and 0.534) in the testing and validation cohorts, (p < 0.05), respectively. The high-risk patients predicted by ERS had significantly higher postoperative 1-year recurrence rates than their low-risk counterparts in both the testing cohort (81.4% vs 22.5%, p < 0.001) and the validation cohort (81.2% vs 26.7%, p = 0.003). The ERS noninvasively predicted early recurrence in resectable PDAC, outperforming the AJCC TNM system. Question More accurately risk-stratifying PDAC patients would allow for better treatment planning. Findings Perineural invasion on CT, lymph nodes metastasis on CT, tumor necrosis, and CA19-9 were associated with early recurrence of resectable PDAC. Clinical relevance The ERS system showed better predictive performance for early recurrence in resectable PDAC and outperformed the American Joint Commission on Cancer TNM system.