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Background: Retrospective analysis to investigate the relationship between the flow-metabolic phenotype and overall survival (OS) of pancreatic ductal adenocarcinoma (PDAC) and its potential clinical utility., Methods: Patients with histopathologically proven PDAC between 2005 and 2014 using tumor attenuation on routine pre-operative CECT as a surrogate for the vascularity and [ 18 F]FDG-uptake as a surrogate for metabolic activity on [ 18 F]FDG-PET., Results: In total, 93 patients (50 male, 43 female, median age 63) were included. Hypoattenuating PDAC with high [ 18 F]FDG-uptake has the poorest prognosis (median OS 7 ± 1 months), compared to hypoattenuating PDAC with low [ 18 F]FDG-uptake (median OS 11 ± 3 months; p = 0.176), iso- or hyperattenuating PDAC with high [ 18 F]FDG-uptake (median OS 15 ± 5 months; p = 0.004) and iso- or hyperattenuating PDAC with low [ 18 F]FDG-uptake (median OS 23 ± 4 months; p = 0.035). In multivariate analysis, surgery combined with tumor differentiation, tumor stage, systemic therapy and flow metabolic phenotype remained independent predictors for overall survival., Discussion: The novel qualitative flow-metabolic phenotype of PDAC using a combination of CECT and [ 18 F]FDG-PET features, predicted significantly worse survival for hypoattenuating-high uptake pancreatic cancers compared to the other phenotypes., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)