AI-driven tumor heterogeneity quantification and survival prediction in pancreatic ductal adenocarcinoma.

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignancies worldwide, and accurate prognostic prediction remains highly challenging due to its marked biological heterogeneity and complex tumor microenvironment. To address this challenge, a histopathomics-based survival prediction system (HPSurv) was developed using histopathological whole-slide images (WSIs) for individualized overall survival (OS) prediction. Within this framework, pathological tissue classification, quantitative characterization of tumor spatial heterogeneity, and a survival Transformer were integrated to enable multi-level representation learning from histopathological data. The system was developed and evaluated in 1020 patients across five independent cohorts. Compared with conventional clinicopathological indicators, significantly improved prognostic performance was achieved across multicenter cohorts (p < 0.05), with a mean C-index of 0.761 and time-dependent AUCs of 0.936, 0.877, and 0.772 for predicting 6-month, 2-year, and 3-year survival, respectively. Subgroup analyses further supported its role as an independent prognostic factor and suggested its potential utility in stratifying patients with respect to ACT-related outcomes. In addition, significant associations with key PDAC molecular pathways were observed, providing biological insights into the model predictions and supporting interpretability. In the study, an interpretable and high-performing artificial intelligence (AI) framework for quantitative modeling of PDAC was established. Objective characterization of tumor heterogeneity and accurate postoperative survival prediction are enabled, with potential value for personalized management in PDAC.