Podocalyxin overexpression associates with poor survival in pancreatic cancer (PDAC). We investigated whether podocalyxin expression correlates with treatment response or survival in neoadjuvant-treated PDAC. Through immunohistochemistry, we evaluated podocalyxin expression in 88 neoadjuvant and 143 upfront surgery patients using two antibodies. We developed a six-tier grading scheme for neoadjuvant responses evaluating the remaining tumor cells in surgical specimens. Strong podocalyxin immunopositivity associated with poor survival in the patients responding poorly to the neoadjuvant treatment (HR 4.16, 95% CI 1.56-11.01, p = 0.004), although neoadjuvant patients exhibited generally low podocalyxin expression (p = 0.017). Strong podocalyxin expression associated with perineural invasion (p = 0.003) and lack of radiation (p = 0.036). Two patients exhibited a complete neoadjuvant response, while a strong neoadjuvant response (≤ 5% of residual tumor cells) significantly associated with lower stage, pT-class and grade, less spread to the regional lymph nodes, less perineural invasion, and podocalyxin negativity (p < 0.05, respectively). A strong response predicted better survival (HR 0.28, 95% CI 0.09-0.94, p = 0.039). In conclusion, strong podocalyxin expression associates with poor survival among poorly responding neoadjuvant patients. A good response associates with podocalyxin negativity. A strong response associates with better outcome.Pancreatic cancer has now become the third most common cause of cancer-related death. In recent decades, the incidence of pancreatic cancer has increased, and survival rates remain poor and largely unchanged, with an overall five-year survival rate of 6% to 10% 1 . Under the most optimal situation, with localized, resectable disease, five-year survival can reach up to 37% [2][3][4] .Many studies have shown that neoadjuvant therapy (NAT) is safe and effective for locally advanced and borderline-resectable disease [5][6][7][8][9] . Assessing the histological NAT effect in a post-pancreatectomy pancreatic ductal adenocarcinoma (PDAC) specimen is challenging, since some histological features of the treatment response, such as necrosis, fibrosis, and tumor cell atypia, overlap with features seen in untreated PDAC 10 . Furthermore, few schemes for evaluating the histopathological grading of the residual, viable tumor cells in the post-pancreatectomy specimen have emerged. Such schemes rely on the percentage of visible, severely degenerative, or viable residual cancer cells in the specimen [11][12][13][14] . Among these schemes, the Evans and the College of American Pathologists (CAP) grading systems appear to correlate with overall and disease-free survival (DFS) [15][16][17] . These systems have been criticized, however, for their lack of precision, clarity, simplicity, and clinical utility 18 . Recently, the Amsterdam International Consensus Meeting provided an overview listing statements regarding neoadjuvant response scoring in pancreatic cancer. Among other statements, response sh...