Multi-parametric MRI Diffusion Models Combined with Clinical Information for Predicting Ki-67 Expression in Pancreatic Ductal Adenocarcinoma: A Prospective Cohort Study

Purpose To evaluate the diagnostic value of intravoxel incoherent motion (IVIM) and diffusion kurtosis imaging (DKI) parameters combined with clinical information for predicting Ki-67 expression in pancreatic ductal adenocarcinoma (PDAC). Methods This prospective cohort study enrolled 65 patients with histopathologically confirmed PDAC between January 2024 and May 2025. All patients underwent 3.0T MRI including conventional sequences and advanced diffusion-weighted imaging sequences. Clinical data and laboratory parameters were collected within one week before surgery or biopsy. Ki-67 expression was assessed using immunohistochemical staining with 50% as the cutoff value. Two radiologists independently performed quantitative measurements with excellent inter-observer reliability (ICC > 0.85). Univariate and multivariate logistic regression analyses identified independent predictors. ROC curve analysis and DeLong test evaluated diagnostic performance. Results Based on Ki-67 expression threshold of 50%, 48 patients (73.8%) were classified as low expression and 17 patients (26.2%) as high expression. Compared to the low Ki-67 group, the high expression group demonstrated significantly lower monocyte count (0.35 ± 0.09 vs 0.49 ± 0.16×10⁹/L, P = 0.001), higher IVIM perfusion fraction f-value (14.08 ± 3.41% vs 10.90 ± 3.83%, P = 0.004), and lower DKI mean diffusivity MD-value (1.26 ± 0.17 vs 1.65 ± 0.17×10⁻³ mm²/s, P < 0.001). Individual prediction models achieved AUCs of 0.763 (monocyte count), 0.732 (IVIM-f), and 0.800 (DKI-MD). The combined prediction model integrating these three parameters demonstrated excellent diagnostic performance with AUC of 0.913 (95% CI: 0.841–0.985), sensitivity of 82.4%, and specificity of 83.3%, significantly outperforming all individual models (P < 0.001). Conclusion This multi-parametric combined prediction model achieves excellent diagnostic performance for preoperative non-invasive assessment of Ki-67 expression status in PDAC, providing a reliable tool for precision medicine practice and personalized treatment strategies.