Early Pancreatic Cancer: Clinical Implications, Workup, and Imaging Findings with Histopathologic Correlation for Personalized Surveillance.

Pancreatic cancer represents a major global health challenge marked by an increasing incidence, poor prognosis, and high mortality rate. Multiple risk factors and predisposing conditions contribute to the development of pancreatic cancer. Major modifiable risks include cigarette smoking, obesity, diabetes, and alcohol consumption. Genetic predisposition also plays a significant role in pancreatic cancer, with 5%-10% of cases linked to hereditary syndromes. In addition, precancerous lesions such as pancreatic intraepithelial neoplasia and intraductal papillary mucinous neoplasms are clinically important due to their potential to progress to pancreatic ductal adenocarcinoma. Early detection of pancreatic cancer at a surgically resectable stage offers a key opportunity to improve the dismal prognosis associated with this disease. In this review, early pancreatic cancer refers to high-grade-dysplasia precursor lesions and 2-cm or smaller invasive carcinomas that remain confined to the pancreas. Imaging is pivotal in the early detection of pancreatic cancer, with radiologic advancements making early diagnosis increasingly achievable and offering the potential to significantly improve outcomes in patients with this highly fatal disease. Early-stage disease can be detected through direct imaging findings, such as a solid lesion or an enhancing mural nodule within a cystic lesion, and indirect features, including pancreatic parenchyma and ductal system changes. These indirect findings can precede tumor visualization by 1-5 years, offering a vital window for early intervention. Because early-stage lesions are often microscopic, careful interpretation of subtle imaging features is essential for informed clinical decision making. Radiologists should recognize subtle imaging features that may precede overt tumor development, aiding effective multidisciplinary decision making and timely management. ©RSNA, 2026 Supplemental material is available for this article. See the invited commentary by Miller in this issue.