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Despite careful selection, the recurrence rate after upfront surgery for pancreatic adenocarcinoma can be very high. We aimed to construct and validate a model for the prediction of early distant recurrence (&lt;12 months from index surgery) after upfront pancreaticoduodenectomy. After exclusions, 147 patients were retrospectively enrolled. Preoperative clinical and radiological (CT-based) data were systematically evaluated; moreover, 182 radiomics features (RFs) were extracted. Most significant RFs were selected using minimum redundancy, robustness against delineation uncertainty and an original machine learning bootstrap-based method. Patients were split into training ( n = 94) and validation cohort ( n = 53). Multivariable Cox regression analysis was first applied on the training cohort; the resulting prognostic index was then tested in the validation cohort. Clinical (serum level of CA19.9), radiological (necrosis), and radiomic (SurfAreaToVolumeRatio) features were significantly associated with the early resurge of distant recurrence. The model combining these three variables performed well in the training cohort ( p = 0.0015, HR = 3.58, 95%CI = 1.98-6.71) and was then confirmed in the validation cohort ( p = 0.0178, HR = 5.06, 95%CI = 1.75-14.58). The comparison of survival curves between low and high-risk patients showed a p -value &lt;0.0001. Our model may help to better define resectability status, thus providing an actual aid for pancreatic adenocarcinoma patients' management (upfront surgery vs. neoadjuvant chemotherapy). Independent validations are warranted.

Prediction of Early Distant Recurrence in Upfront Resectable Pancreatic Adenocarcinoma: A Multidisciplinary, Machine Learning-Based Approach