Pancreatic cancer is the most deadly of all gastrointestinal malignancies and has a very poor prognosis. Unfortunately, most patients present late in the course of their disease and, at the time of diagnosis, only 10 to 25% of patients will be eligible for potentially curative resection. Efforts must be oriented towards an early diagnosis and towards reliably identifying patients who can really benefit from major surgery. A suspected pancreatic tumor can be a difficult challenge for the clinician. In the last ten years, we have witnessed notable technological improvements in radiological and nuclear imaging. Taking this into account, we will try to delineate the new role of endoscopic ultrasound (EUS) in pancreatic tumor imaging and to place EUS in a shareable diagnostic and staging algorithm. To date, the most accurate imaging techniques for pancreatic neoplasms remain contrast-enhanced computed tomography and EUS. EUS has the highest accuracy in detecting small lesions, in assessing tumor size and lymph node involvement, but helical CT must still be the first choice in patients with a suspected pancreatic tumor. However, after this first step, there is a place for EUS as a second diagnostic level in several cases: negative results on CT scan and persistent strong clinical suspicion of pancreatic cancer, doubtful results on CT scans or the need for cytohistological confirmation. In the near future, there will be great opportunities for the development of diagnostic and therapeutic EUS and pancreatic cancer could be the best testing ground.
