BACKGROUND Accurate staging of pancreatic cancer is essential for surgical planning and for identification of locally advanced and metastatic disease that is incurable by surgery. Advances in endoscopic sonography (EUS), computed tomography (CT), and positron emission tomography have improved the accuracy of staging and reduced the number of incomplete surgical resections. Tissue acquisition is necessary in nonsurgical cases when chemoradiotherapy is considered. The complex regional anatomy of the pancreas makes cytologic diagnosis of malignancy at this region difficult without exploratory surgery. Although CT-guided fine-needle aspiration (FNA) is used for this purpose, reports of an increased risk of peritoneal dissemination of cancer cells and a false-negative rate of nearly 20% make this a poor choice. The ability to position the EUS-transducer in direct proximity to the pancreas by means of the stomach and duodenum, combined with the use of FNA, increases the specificity of EUS in detecting pancreatic malignancies. METHODS The current literature regarding the accuracy of EUS with FNA in the evaluation of pancreatic cancer is reviewed. RESULTS EUS accuracy ranges from 78% to 94% for tumor staging and from 64% to 82% for nodal staging. EUS also enables FNA of lesions that are too small to be identified by CT or MRI or too well encased by surrounding vascular structures to safely allow percutaneous biopsy. The accuracy for detecting invasion into the superior mesenteric artery and vein is lower than that for detecting portal or splenic vein invasion, especially for large tumors. EUS permits delivery of localized therapy such as celiac plexus neurolysis for pain control and direct intra-lesional injection of antitumor therapy. CONCLUSIONS EUS in combination with FNA is a highly accurate method of preoperative staging of pancreatic cancer, especially those too small to be characterized by CT or MRI, and it has the ability to obtain cytological confirmation of pancreatic cancer.