Endosonographic workup and preoperative biliary drainage for pancreatic cancer

Computed tomography (CT) is the primary imaging modality for initial evaluation of pancreatic cancer (PC). Endoscopic ultrasound (EUS) has a higher sensitivity for detection of PC and is better especially for lesions<3 cm. It should be the next step if the CT scan is indeterminate, or negative in the presence of high suspicion of PC based on clinical and laboratory data. EUS-guided fine-needle aspiration (FNA) should be performed for lesions found on EUS after negative or indeterminate CT, for borderline resectable pancreatic cancer (BRPC) and unresectable cancer, or if the patient is being considered for neoadjuvant or palliative chemotherapy. EUS elastography and contrast-enhanced harmonic EUS are new and promising EUS technologies that may detect lesions missed by other modalities and may help guide EUS-FNA to target lesions.