Early diagnosis and appropriate staging of pancreatic adenocarcinoma is of vital importance to possibly detect this otherwise lethal disease at a curable phase and to stratify patients who would benefit the most from surgical resection. The availability of endoscopic ultrasound (EUS) with its unique capability of obtaining refine images of the pancreas has represented a major breakthrough in the management of these difficult tasks. Furthermore, the ability to perform fine needle aspiration (FNA) under real time EUS guidance has offered the possibility to reach a definite diagnosis which has a major impact on the decision making process in the care of patients with both resectable and unresecectable pancreatic cancer. In parallel to the widespread importance of diagnostic EUS, the therapeutic applications of EUS are increasing and may further expand the role of this procedure in the management of pancreatic cancer. This article focuses on the current role of EUS and EUS-FNA in the diagnosis and staging of solid pancreatic lesions in different clinical scenarios, including those individuals at a high risk of developing pancreatic cancer and who may be candidates for a EUS-based screening and surveillance program. Data on the emerging therapeutic role of EUS for pancreatic cancer treatment will also be reviewed.