To evaluate a combined approach using EUS-guided real-time elastography (RTE) and mesenchymal immunohistochemical markers to predict prognosis in pancreatic cancer.

Twenty-three consecutive patients diagnosed with PC by EUS-FNB at the Research Center for Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, between January and April 2025, were enrolled. All patients underwent RTE-EUS using the ARIETTA 850 system. Histopathology confirmed the diagnosis, and immunohistochemistry for α-SMA and vimentin was performed to assess mesenchymal activation. Quantitative morphologic and textural classifiers were automatically generated using Image ProPlus AMS analysis software, including: hole area, roundness, heterogeneity, integrated optical density (IOD), Feret max, Feret mean, fractal dimension, and clumpiness.

High expression of α-SMA and vimentin was significantly associated with the presence of metastases and decreased survival (p < 0.05). Morphologic classifiers applied to both elastography and IHC images demonstrated increased stiffness and dense fibrosis in advanced disease stages. Significant associations were found for heterogeneity, IOD, Feret max, Feret mean, fractal dimension, and clumpiness (p < 0.001), and for hole area and roundness (p < 0.05).

This study highlights the potential of EUS-RTE as a real-time imaging tool for improving prognostic assessment in PDAC by integrating mesenchymal marker–based quantitative denominators. Combined elastography–IHC analysis may contribute to more refined risk stratification and personalized management.