AIM: This study aimed to develop and validate a deep learning radiomics nomogram (DLRN) derived from ultrasound images to improve predictive accuracy for lymph node metastasis (LNM) in pancreatic cancer (PC) patients.

METHODS: A retrospective analysis of 249 histopathologically confirmed PC cases, including 78 with LNM, was conducted, with an 8:2 division into training and testing cohorts. Eight transfer learning models and a baseline logistic regression model incorporating handcrafted radiomic and clinicopathological features were developed to evaluate predictive performance. Diagnostic effectiveness was assessed for junior and senior ultrasound physicians, both with and without DLRN assistance.

RESULTS: InceptionV3 showed the highest performance among DL models (AUC = 0.844), while the DLRN model, integrating deep learning and radiomic features, demonstrated superior accuracy (AUC = 0.909), robust calibration, and significant clinical utility per decision curve analysis. DLRN assistance notably enhanced diagnostic performance, with AUC improvements of 0.238 (p = 0.006) for junior and 0.152 (p = 0.085) for senior physicians.

CONCLUSION: The ultrasound-based DLRN model exhibits strong predictive capability for LNM in PC, offering a valuable decision-support tool that bolsters diagnostic accuracy, especially among less experienced clinicians, thereby supporting more tailored therapeutic strategies for PC patients.